COMMUNITY

NUTRITION
ASMA AFREEN
OVERVIEW OF COURSE
1. Epidemiology – the foundation of community nutrition
2. Nutrition in Pakistan
3. Professional approach to community nutrition
4. Working with special groups in a complex environment
5. Nutrition policy, health care reform and population
6. Primary prevention of diseases
7. Four priority areas of reducing food borne diseases
8. Preventing single and cluster diseases
9. Preventing nutrition link diseases
COMMUNITY NUTRITION
• Community nutrition encompasses a broad set of
activities designed to provide access to a safe,
adequate, healthful diet to a population living in a
particular geographic area.

• These activities include nutrition education, nutrition or

health promotion, food programs, supplementation
programs, preventive programs, local policy analysis and
development, and the organizational infrastructure that
supports it.
Cont….
• “Ideally, community nutrition involves four interrelated
steps to deliver services:

• assessment to identify the problem(s),

• planning to meet the community nutrition needs,
• implementation to develop systems to reduce the
problem and
• evaluation to see if the problem has been solved or not.”
Cont…. Other definitions
• Community nutrition encompasses individual and interpersonal-
level interventions focused on creating changes in knowledge,
attitudes, behavior and health outcomes either individually or in
small groups within a community setting.

• Community nutritionists are professionals trained in the delivery of

preventive and therapeutic nutrition services within community
settings.

• These individuals have training in nutrition throughout the life-span,

nutrition education and counseling, and program development, and
are registered dietitians or licensed dietitians/nutritionists.
Cont….
• The main functions of community nutritionists include:

• conducting and evaluating nutrition education and counseling

for small groups and individuals;

• planning, implementing, and evaluating primary and

secondary prevention interventions;

• providing therapeutic and rehabilitation nutrition services;

• administering programs.
Examples:
1.Conducting food demonstrations/classes for individuals enrolled
in the Supplemental Nutrition Assistance Program (SNAP).
2. Training peer counselors and promoter .
3. Conducting in-service education for school foodservice
personnel.
4. Developing nutrition education activities for the school
classroom.
5. Providing technical assistance/consultation to health providers
on case management for nutrition and dietetics-related issues ;
6. Participating in an interdisciplinary team conducting home visits.
The Concept of Community
• The concept of community varies widely. The World Health
Organization (WHO) defines
• Community as “a social group determined by geographic
boundaries and/or common values and interests.”

• Community members know and interact with one another;

function within a particular social structure; and show and create
norms, values, and social institutions.
• A second definition of community is demographic and involves
viewing the community as a subgroup of the population, such as
people of a particular age, gender, social class, or race.
Cont….
• A community can also be defined on the basis of a common
interest or goal. A collection of people, even if they are
scattered geographically, can have a common interest that
binds its members. This is called a common-interest
community.

• Many successful prevention and health promotion efforts,

including improved services and increased community
awareness of specific problems , have resulted from the work
of common-interest communities.
Public health nutrition
• Public health nutrition is the application of nutrition and public
health principles to improve or maintain optimal health of
populations and targeted groups through enhancements in
programs, systems, policies, and environment.

• Public health nutritionists are professionals trained in both

nutrition and the core competency areas of public health.
The main functions of public health
nutritionists include:
• taking a leadership role in identifying nutrition-related needs
of a community;
• planning, directing, and evaluating health promotion and
disease prevention efforts;
• administering and managing programs, including supervising
personnel;
• developing and/or assisting in the preparation of a budget;
• identifying and seeking resources (e.g., grants, contracts) to
support programs and services;
Cont….
• providing therapeutic and rehabilitation nutrition services, when
these needs are not adequately met by other parts of the health
care system;
• providing technical assistance/consultation to policy makers,
administrators, and other health agency personnel;
• collaborating with others to promote environmental and systems
changes;
• assuring access to healthful and affordable food and nutrition-
related care;
• advocate for and participating in policy development and
evaluation of the impacts and outcomes; and,
• participating in research, demonstration and evaluation projects.
Examples:
1. Collaborating with city planners to change environments to
increase access, availability, affordability of healthful food
options, such as, providing tax incentives to full service
grocery stores to locate in rural areas.
2. Developing policies to impact healthy eating and physical
activity, such as, working with transportation departments to
promote safe and reliable access to healthy and affordable food
venues.
3. Developing and implementing policies and procedures to
promote healthy practices in the workplace.
UNIT 1-EPIDEMIOLOGY – THE
FOUNDATION OF COMMUNITY NUTRITION
OVERVIEW:
• EPIDEMIOLOGY’S EARLY HISTORY
• MODERN EPIDEMIOLOGY
• NUTRITIONAL EPIDEMIOLOGY
• THE TERRITORY OF EPIDEMIOLOGY-PRINCIPLE AND
APPLICATION
• THE LINK BETWEEN EATING BEHAVIOR AND
CHRONIC DISEASE
• RESEARCH DIRECTIONS
Classically speaking
• Epi = upon
• Demos = people
• Ology = science
• Epidemiology = the science which deals with what falls upon
people…..
• Bridge between biomedical, social and behavioral sciences
 Simple Old Definitions
Oxford English Dictionary
THE BRANCH OF MEDICAL SCIENCE WHICH TREATS
EPIDEMICS
Kuller LH: American J of Epidemiology 1991;134:1051
EPIDEMIOLOGY IS THE STUDY OF "EPIDEMICS" AND
THEIR PREVENTION
Anderson G. In: Rothman KJ: Modern Epidemiology
THE STUDY OF THE OCCURRENCE OF ILLNESS
 Epidemiologists are required to have some
knowledge of:

• Public health: because of the emphasis on disease prevention

•Clinical medicine: because of the emphasis on disease classification and
diagnosis
• Pathophysiology: because of the need to understand basic biological
mechanisms in disease (natural history)
• Biostatistics: because of the need to quantify disease frequency and its
relationships to antecedents (testing hypotheses)
• Social sciences: because of the need to understand the social context in which
disease occurs and presents (social determinants of health phenomena)
A Modern Definition

Study of the occurrence and distribution of health-

related diseases or events in specified populations,
including the study of the determinants influencing
such states, and the application of this knowledge to
control the health problem
(Porta M, Last J, Greenland S. A Dictionary of
Epidemiology, 2008)
Cont….
• Epidemiology is the study of the patterns, causes, and
effects of health and disease conditions in defined
populations.
• It is the cornerstone of public health, and shapes
policy decisions and evidence-based practice by
identifying risk factors for disease and targets for
preventive healthcare.
• Epidemiologists help with study design, collection,
and statistical analysis of data, and interpretation and
dissemination of results.
EPIDEMIOLOGY’S EARLY
HISTORY
• The history of infectious diseases can be conveniently divided
into three broad phases.
• The earliest phase, such as appears in the Hippocratic treatises,
was that of clinical description with relatively few specific
preventive or therapeutic measures.
•  Hippocrates collected data and conducted experiments to show
that disease was a natural process; that the signs and symptoms
of a disease were caused by the natural reactions of the body to
the disease process; and that the chief role of the physician was
to aid the natural resistance of the body to overcome the
metabolic imbalance and restore health and harmony to the
organism.  
Cont….
• He separated the discipline of medicine from
religion, believing and arguing that disease was
not a punishment inflicted by the gods but
rather the product of environmental factors,
diet, and living habits.
Cont….
• The second, occurring mainly during the eighteenth
and nineteenth centuries, was the time when the
Hippocratic and Galenic doctrines that had dominated
medical thought for centuries were being overthrown.

• held that disease was a consequence of imbalance

between natural forces within and outside the body,
and therapy was directed toward restoring this
balance.
CONT….
• The third phase, characterized by the logarithmic
growth of knowledge and of scientific exploration,
was a period that received its greatest stimulus from
the discovery of specific microbial causes of Disease
by Pasteur and Koch, which blossomed into the
present era of scientific exploration of disease.
Cont….
• The contributions of some of these early and more
recent thinkers are described below.
Circa 400 B.C.
• Epidemiology's roots are nearly 2500 years old.
• Hippocrates attempted to explain disease occurrence
from a rational rather than a supernatural viewpoint.
• In his essay entitled “On Airs, Waters, and Places,”
Hippocrates suggested that environmental and host
factors such as behaviors might influence the
development of disease.
1662
• Another early contributor to epidemiology was John
Graunt, a London councilman who published a
landmark analysis of mortality data in 1662.

• This publication was the first to quantify patterns of

birth, death, and disease occurrence, noting disparities
between males and females, high infant mortality,
urban/rural differences, and seasonal variations.
1800
• William Farr built upon Graunt's work by
systematically collecting and analyzing Britain's
mortality statistics.
• Farr, considered the father of modern vital statistics
and surveillance, developed many of the basic
practices used today in vital statistics.
• He concentrated his efforts on collecting vital
statistics, assembling and evaluating those data, and
reporting to responsible health authorities and the
general public.
1854
• In the mid-1800s, an anesthesiologist named John Snow was
conducting a series of investigations in London being
considered the “father of field epidemiology.” Twenty years
before the development of the microscope, Snow conducted
studies of cholera outbreaks both to discover the cause of
disease and to prevent its recurrence. Because his work
illustrates the classic sequence from descriptive epidemiology
to hypothesis generation to hypothesis testing (analytic
epidemiology) to application, two of his investigations will be
described in detail.
Cont….
• Snow conducted one of his now famous studies in
1854 when an epidemic of cholera erupted in the
Golden Square of London. He began his investigation
by determining where in this area persons with
cholera lived and worked. He marked each residence
on a map of the area, as shown in Figure 1.1. Today,
this type of map, showing the geographic distribution
of cases, is called a spot map.
Spot map of deaths from cholera in
Golden Square area,
Figure 1.1 Spot map London,
of deaths from cholera in Golden 1854
Square area, London, 1854 (redrawn
original)

Image Description
Cont…..
• Because Snow believed that water was a source of infection for cholera, he
marked the location of water pumps on his spot map, then looked for a
relationship between the distribution of households with cases of cholera
and the location of pumps.

• He noticed that more case households clustered around Pump A, the Broad
Street pump, than around Pump B or C. When he questioned residents who
lived in the Golden Square area, he was told that they avoided Pump B
because it was grossly contaminated, and that Pump C was located too
inconveniently for most of them. From this information, Snow concluded
that the Broad Street pump (Pump A) was the primary source of water and
the most likely source of infection for most persons with cholera in the
Golden Square area. He noted with curiosity, however, that no cases of
cholera had occurred in a two-block area just to the east of the Broad Street
pump.
Cont….
• Upon investigating, Snow found a brewery located there with a
deep well on the premises. Brewery workers got their water from
this well, and also received a daily portion of malt liquor. Access to
these uncontaminated rations could explain why none of the
brewery's employees contracted cholera.

• To confirm that the Broad Street pump was the source of the
epidemic, Snow gathered information on where persons with
cholera had obtained their water. Consumption of water from the
Broad Street pump was the one common factor among the cholera
patients. After Snow presented his findings to municipal officials,
the handle of the pump was removed and the outbreak ended. The
site of the pump is now marked by a plaque mounted on the wall
outside of the appropriately named John Snow Pub.
Cont….
• Snow's second investigation reexamined data from the 1854 cholera
outbreak in London. During a cholera epidemic a few years earlier, Snow
had noted that districts with the highest death rates were serviced by two
water companies: the Lambeth Company and the Southwark and Vauxhall
Company.
• At that time, both companies obtained water from the Thames River at
intake points that were downstream from London and thus susceptible to
contamination from London sewage, which was discharged directly into
the Thames. To avoid contamination by London sewage, in 1852 the
Lambeth Company moved its intake water works to a site on the Thames
well upstream from London. Over a 7-week period during the summer of
1854, Snow compared cholera mortality among districts that received
water from one or the other or both water companies. The results are
shown in Table 1.1.
Cont….
• This study, demonstrating a higher death rate from cholera
among households served by the Southwark and Vauxhall
Company in the mixed districts, added support to Snow's
hypothesis.
• It also established the sequence of steps used by current-day
epidemiologists to investigate outbreaks of disease.
• Based on a characterization of the cases and population at risk
by time, place, and person, Snow developed a testable
hypothesis.
Cont….
• After this study, efforts to control the epidemic were directed at
changing the location of the water intake of the Southwark and
Vauxhall Company to avoid sources of contamination.

• Thus, with no knowledge of the existence of microorganisms,

Snow demonstrated through epidemiologic studies that water
could serve as a vehicle for transmitting cholera and that
epidemiologic information could be used to direct prompt and
appropriate public health action.
19th and 20th centuries
• In the mid- and late-1800s, epidemiological methods began to
be applied in the investigation of disease occurrence.
• At that time, most investigators focused on acute infectious
diseases. In the 1930s and 1940s, epidemiologists extended
their methods to noninfectious diseases.
• The period since World War II has seen an explosion in the
development of research methods of epidemiology.

• Epidemiology has been applied to the entire range of health-

related outcomes, behaviors, and even knowledge and
attitudes.
Cont….
• The studies by Doll and Hill linking lung cancer to smoking
and the study of cardiovascular disease among residents of
Framingham are two examples of how pioneering researchers
have applied epidemiologic methods to chronic disease since
World War II.

• During the 1960s and early 1970s health workers applied

epidemiologic methods to eradicate naturally occurring
smallpox worldwide.
• This was an achievement in applied epidemiology.
Cont…..
• In the 1980s, epidemiology was extended to the studies of
injuries and violence.
• In the 1990s, the related fields of molecular and genetic
epidemiology (expansion of epidemiology to look at specific
pathways, molecules and genes that influence risk of developing
disease) took root.
• Meanwhile, infectious diseases continued to challenge
epidemiologists as new infectious agents emerged (Ebola virus,
Human Immunodeficiency virus (HIV)/ Acquired
Immunodeficiency Syndrome (AIDS)), were identified
(Legionella, Severe Acute Respiratory Syndrome (SARS)), or
changed (drug-resistant Mycobacterium tuberculosis, influenza).
Cont…..
• Beginning in the 1990s and accelerating
after the terrorist attacks of September 11,
2001, epidemiologists have had to
consider not only natural transmission of
infectious organisms but also deliberate
spread through biologic warfare and
bioterrorism.
Cont…..

• Today, public health workers throughout the world

accept and use epidemiology regularly to characterize
the health of their communities and to solve day-to-
day problems, large and small.
MODERN EPIDEMIOLOGY
• By 1900s epidemiologic methods were extended to non-
infectious diseases.
• Since world war II, research methods and theoretical
frameworks for epidemiological exploration have flourished.
•
• E.g. behaviors, knowledge and attitudes of individuals and
groups have been evaluated as predisposing or antecedent to
the occurrence of health events.
NUTRITIONAL EPIDEMIOLOGY
• Nutritional epidemiology is a relatively new field of medical
research that studies the relationship between nutrition and
health.

• Diet and physical activity are difficult to measure accurately,

which may partly explain why nutrition has received less
attention than other risk factors for disease in epidemiology.
School of public health, university of
Washington
• Nutritional epidemiology is an area of epidemiology that
involves research to:

• Examine the role of nutrition in the etiology of disease.

• Monitor the nutritional status of populations.
• Develop and evaluate interventions to achieve and maintain
healthful eating patterns among populations.
• Examine the relationship and synergy between nutrition and
physical activity in health and disease.
Cont.….
• Knowledge and common wisdom about the
importance of diet have been handed down from
generation to generation for millennia.
• While the formal study of diet and health is only a few
decades old, the importance of diet to maintain health
was already known to the ancient Greeks. As
Hippocrates (460–377 BC), the father of Western
medicine, put it: ‘If we could give every individual
the right amount of nourishment and exercise, not too
little and not too much, we would have found the
safest way to health.
Cont….
• The first population-based studies collecting information on
nutrition were conducted in the 20th century.

• Data on only a few foods were collected generally and were

cross-classified with disease outcomes.

• More detailed dietary assessment instruments were

subsequently developed, the most popular of which are the 24-
hour recall, a food diary kept for several days, and the food
frequency questionnaire (FFQ).
The epidemiology of Scurvy
• James Lind (1716-1794) , a Scottish naval surgeon , one of the
first who did experimental trial of a nutrition based disease
which was common on all long trips by sea. Their breakfast
consisted of water and sweetened gruel, and other meals
consisted of fresh mutton broth, with a boiled sweet biscuits.
Sometime barley and raisins, rice and currants or sago and
wine were served.
• They developed symptoms of bleeding gums, bleeding under
the skin and extreme weakness after 4-6 wks. at sea.
Five strategies
• Lind devised a modern intervention trial with following strategies.
1. Once a day, 2 pts. received a quart of cider to gargle and then
swallow on an empty stomach.
2. 2 pts. were given 2 spoons of vinegar, 3 times a day on an empty
stomach, and had vinegar added to their cereals and other foods.
They were also required to gargle with vinegar.
3. 2 pts. Drank a half pint of sea water every day.
4. Two others received 2 oranges and 1 lemon every day on an empty
stomach.
5. The final pair consumed a mixture consisting of Nutmeg tree,
garlic, mustard seed and other herbs. They also drank barley water
that was mixed with tamarind.
Cont.….
• The men who consumed oranges and lemons had the most
rapid recovery and reported to duty after 06 days. Their bloody
gums disappeared and they appeared healthy before the ship
reached on land.

• The result of this experiment was the identification of an

effective therapeutic agent for treating a disorder and
preventing its occurrence. The experiment resulted in a health
policy in 1795 that required that limes or lime juice be
included in the meals of all sailors. Thus sailors were
nicknamed as “limeys”.
Cont.….
• Epidemiology of Beri Beri (1858-1930- Eijkman)
• Epidemiology of Rickets (1861-1947- Frederic Hopkins)
• Epidemiology of vitamin D and cod liver oil (1883-1940- Kurt
Huldschinsky)
• Epidemiology of Pellagra (1923 –Joseph Goldberger)

• These classical studies and events laid the groundwork for nutritional
epidemiology. And simply defined that Nutritional epidemiology is the
study of eating behavior and how it influences the etiology, occurrence,
prevention and treatment of disease.

• Eating behavior (rather than diet) and specific methods to collects data
about eating behavior and its relation to wellness and diseases are the
essence of NE.
Cont….
• NE is the great-grand child and hybrid of epidemiology,
nutrition and public health. The sequence of development
might be envisioned as follows:
• Public Health Epidemiology Public Health Nutrition
Community Nutrition Nutritional Epidemiology

• CN is a contemporary and comprehensive discipline that

encompasses among other disciplines, public health nutrition.
Public health nutrition---
PHN has developed in response to numerous societal events and
changes, including the following.
• Infant mortality
• Epidemics of communicable diseases
• Poor hygiene and sanitation, malnutrition
• Agriculture and food production
• Economic depression, wars, civil rights
• Aging of the population
• Behavior-related problems
• Poverty, immigration
• Preschool/after school child care and school based meals.
Cont…..
• As PHN has evolved, professional practice standards
and training qualifications has developed.
• Assessing, screening and monitoring individual,
groups and communities have become more common.

• Indicators of effectiveness and efficiency have been

identified and have set the stage for improved
opportunities for research.

• The process of NE is dynamic.

Cont….
• NE explores what people eat and how long they follow certain
food patterns, how mush people eat on the average and how their
eating patterns change over time, as they age, why they choose
the foods they eat, whether life styles, taste, economics, food
availability, or some other factors has the greatest impact on
health and who eats what.

• The methods used to investigate, monitor, o ensure adherence to

an intervention not only follow the epidemiological process and
study design but also address reliability, validity and
standardization.
Becoz of all these

• Today an environment exists in which chronic

disease control has emerged as a priority.
The territory of epidemiology –
Principles and Application

• Epidemiological methods are tools to

explore disease occurrence, treatment,
prevention and cure.
 Basic triad of epidemiology

The three phenomena assessed in epidemiology

are:
HOST

AGENT ENVIRONMENT
 Agents
• Biological (micro-organisms)
• Physical (temperature, radiation, trauma,
others)
• Chemical (acids, alkalis, poisons, tobacco,
others)
• Environmental (allergens, others)
• Psychological experiences
 Host Factors
• Genetic endowment
• Immunologic status
• Personal characteristics
• Personal behavior
Environment
• Living conditions (housing, water
supply, sewage, etc)
• Atmosphere / climate
• Modes of communication: phenomena
in the environment that bring host
and agent together, such as vehicle,
reservoir, etc)
Study designs
Two Broad Types of Epidemiology:
• Descriptive epidemiology: examining the distribution of
disease in a population, and observing the basic features of its
distribution.

• Analytic epidemiology: investigating a hypothesis about the

cause of disease by studying how exposures relate to disease.
Why “type of study”?

•Design more appropriate studies to get right

answers to the specific questions

• Shape up proposals for getting more valid results

 Types of Epidemiologic Studies

Observational: “natural experience”

Descriptive:
 like newspaper reporting
 has no control or comparison group
complexity

Analytic:
 has a control or comparison group

Experimental: investigator controls

 has an exposed or experimental group plus a
control or comparison group determined by
investigator
TYPES OF OBSERVATIONAL STUDIES

Descriptive Little is known - Identify cases, estimate disease

Studies about the frequency, examine time trend

occurrence, or -
determinants of the
disease

Analytic Enough is known - Test specific etiologic hypotheses

Studies about the d disease, -

specific hypotheses
- Suggest potential for disease
can be tested
prevention
STUDY DESIGN OF DESCRIPTIVE STUDY

• Individual level
• Case reports or case series
• Cross-sectional surveys of individual

• Population level
• Ecological study (Correlational study)
 CASE REPORTS AND CASE SERIES
• Case reports : describe experience of a single patients. Case
reports document unusual medical occurrence and can represent
the first clues in the identification of new diseases.

• Case series : collections of individual case reports. Investigation

of the activities of the individual in case reports can lead to
formulation of a hypothesis.
CASE REPORTS AND CASE SERIES

• Stength
• discover new diseases
• bring background information to form hypothesis
about risk factors
• Weakness
• might base on only one case
• do not have a comparison group
CROSS-SECTIONAL STUDY

Total population

Cases
Character of cross-sectional study
• Collect data for all population; case & healthy people

• Information obtain is the number of total cases at that study

period: prevalence

• Can be either descriptive or analytic, depend on design

CROSS-SECTIONAL STUDY
Analytic
Descriptive
• Exposure
Collected number
and disease
of cases
status
and
arenumber
assessedofsimultaneously
total population

• Can determine
assess onlyassociation
prevalence between
of disease
exposure
or otherand
health
disease
events, also called prevalence study
Cross-sectional study

Defined Population

Gather Data on Exposure and Disease

Exposed Not Not

Exposed exposed: Exposed:
Do not Do not
Have disease have disease Have disease have disease
 Hypothetical illustration of the interrelationship between
an occupational exposure and prevalence of disease

80 well 80 well

Job A 100
(hazardous) Workers 10 change jobs
due to illness
20 ill 10 ill

95 well 95 well
Job B 100
(non-hazardous) Workers
5 ill 10 ill 15 ill

Point X

Prevalence of job A = 20 % ( 20/100 )

Prevalence of job B = 5 % ( 5/100 )
Prevalence ratio =4
Hypothetical illustration of the interrelationship between an
occupational exposure and prevalence of disease

80 well 80 well

Job A 100
(hazardous) Workers 10 change jobs
due to illness
20 ill 10 ill

95 well 95 well
Job B 100
(non-hazardous) Workers
5 ill 10 ill 15 ill

Point Y
Prevalence of job A = 11 % ( 10/90 )
Prevalence of job B = 14 % ( 15/110 )
Prevalence ratio = 0.8
Summary of the study design
Study design

Observational Experimental

Quasi-
Descriptive Analytic
experimental

Case and
Case-control Experimental
serial case

Cross-
Cohort
sectional

Cross-
Ecological
sectional

Ecological
 Analytic study, Cohort study

Population
at risk

Exposed Disease among

exposed?
Usually prospective
and

Disease among
Not Exposed non-exposed?
 Distribution of illness according to exposure
in a cohort study

Ill Not ill Risk

a
Exposed a b a+b
a+b

Not exposed c c
d c+d
c+d

Relative risk = Risk exposed / Risk not exposed

Key features
• Should have follow up period (even in retro-cohort)

• Have confine population

• Comparison group should be as similar as possible

Cohort study
Advantage
• Determine multiple effect of single exposure
• Able to estimate incidence

Disadvantage
• Expensive and time consumed
• Validity of result depend on follow up
 Case-control study

Exposure
Disease
? (Case)

?
No disease
(Control)
Distribution of cases and controls according to exposure in
a case-control study

Cases Controls

Exposed a b

Not exposed c d

Total a+c b+d

Odds of exposure a/c b/d

Odds ratio = OddsE (cases) / OddsE (controls)
Odds
Probability of event
Probability of non-event

• Team A plays 10 games:

• 8 wins
• 2 defeats

• Risk (probability) of losing = 2/10

• Odds of losing = 2/10 = 2/8
8/10
Key features

• Study only some part of the population, especially

among non-case

• Case and control should come from the same source

population, to allow possibility that control could
receive the exposure
Case-control study
Advantage
• Cheap, quick and efficient for rare disease
• Potential role for testing multiple risk factors

Disadvantage
• Sometime difficult to establish relationship between
exposure and disease
OBSERVATIONAL STUDY

Advantage:
• Feasible and practical especially for ethical
concern
• Study population is more represent of the target
population

Limitation:
• Difficult to replicate
• Less control of extraneous factors that will lead to
distortion of the result
• Less secure to make generalization
 Experimental study

• Put afford to control the situation of study factors and

observe effect of them
• Control extraneous factors by holding those factors fix
or randomization to make two groups have the same
distribution of extraneous factors.
• One group of subject is given experimental treatment
and another group (control) is given either none or less
preferable. After a period effect of exposure is measured
and compared between two groups.
 Experimental study

• Randomization is used to allocate subject:

subject get treatment by chance

• One important method to make the result more valid

is called “double blinding”: neither investigator nor
subjects know the treatment to which they have been
allocated
 Main feature of each type of epidemiologic
research
• Experimental :
• artificial manipulation of study factor with
randomization

• Quasi-experimental study :
• artificial manipulation of the study factor without
randomization

• Observational :
• no artificial manipulation of the study factor
Link between eating behavior and
chronic diseases.

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