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Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

• Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
• Fifty four percent of raw case users came from outside the U.S..
• The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
• Twenty-six of the cases in the list are raw cases.
• A third of the cases feature a woman protagonist.
• Orders for Yale SOM case studies increased by almost 50% compared to 2020.
• The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

3.   Hertz Global Holdings (B): Uses of Debt and Equity 2020

4.   Glory, Glory Man United!

5.   Search Fund Company Boards: How CEOs Can Build Boards to Help Them Thrive

6.   The Future of Malls: Was Decline Inevitable?

7.   Strategy for Norway's Pension Fund Global

8.   Prodigy Finance

9.   Design at Mayo

10. Cadbury

11. City Hospital Emergency Room

13. Volkswagen

14. Marina Bay Sands

15. Shake Shack IPO

16. Mastercard

17. Netflix

18. Ant Financial

19. AXA: Creating the New CR Metrics

20. IBM Corporate Service Corps

21. Business Leadership in South Africa's 1994 Reforms

22. Alternative Meat Industry

23. Children's Premier

24. Khalil Tawil and Umi (A)

25. Palm Oil 2016

26. Teach For All: Designing a Global Network

27. What's Next? Search Fund Entrepreneurs Reflect on Life After Exit

28. Searching for a Search Fund Structure: A Student Takes a Tour of Various Options

30. Project Sammaan

31. Commonfund ESG

32. Polaroid

33. Connecticut Green Bank 2018: After the Raid

34. FieldFresh Foods

35. The Alibaba Group

36. 360 State Street: Real Options

37. Herman Miller

38. AgBiome

39. Nathan Cummings Foundation

40. Toyota 2010

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What support can I offer my students around analyzing cases and preparing for discussion?

Case discussions can be a big departure from the norm for students who are used to lecture-based classes. The Case Analysis Coach is an interactive tutorial on reading and analyzing a case study. The Case Study Handbook covers key skills students need to read, understand, discuss and write about cases. The Case Study Handbook is also available as individual chapters to help your students focus on specific skills.

How can I transfer my in-person case teaching plan to an online environment?

The case method can be used in an online environment without sacrificing its benefits. We have compiled a few resources to help you create transformative online learning experiences with the case method. Learn how HBS brought the case method online in this podcast , gather some quick guidance from the article " How to Teach Any Case Online ", review the Teaching Cases Online Guide for a deep dive, and check out our Teaching Online Resources Page for more insights and inspiration.

After 35 years as an academic, I have come to the conclusion that there is a magic in the way Harvard cases are written. Cases go from specific to general, to show students that business situations are amenable to hard headed analysis that then generalize to larger theoretical insights. The students love it! Akshay Rao Professor, General Mills Chair in Marketing at the University of Minnesota

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Business Case Studies

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Many academic and business institutions develop and publish case studies. Some of these organizations provide free access to their case studies:

• Acadia Institute of Case Studies Focuses on entrepreneurship and small business operations.
• Business Case Studies by Company
• Business Ethics Case Analyses
• Canadian Centre for Occupational Health & Safety: Workplace Health Case Studies
• Case Centre Available for a fee.
• Daniels Fund Ethics Initiative Case Studies
• Give to Get Marketing. Marketing and Advertising Case Studies
• HR Open Source Case Studies
• MarketingSherpa Choose "Case Studies" as the content type in the filters.
• MaRS Search for "case study" in the top right search box.
• MERLOT Business Cases
• MIT LearningEdge Case Studies Free case studies by MIT Sloan School of Management.
• Penske. Logistics Case Studies
• Society of Human Resources Management.
• Open Case Studies Project by UBC The Open Case Studies project at UBC brings together faculty and students from different disciplines to write, edit, and learn with case studies that are free and open.
• World's Best Case Studies Short video case studies covering topics including consumer goods, services, and technology.
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Finding case studies

On this page, introduction, finding cases, sample cases, developing and analysing cases.

"Case studies" can mean examples from organizations provided simply to illustrate a point or descriptions of organizational situations designed to be interpreted and analyzed by a learner. The resources below provide a mix of all types of case studies.

This guide also includes some resources that will be of more use to students (e.g., the tips on finding case studies in databases) and other resources that instructors will find useful (e.g., the links to case clearinghouses).

If you don't find what you need here, don't hesitate to ask for help .

  New!  We've recently added another 600+ new cases to our Sage Business Cases resource! 

Try searching the SFU Library catalogue  and include ( case study OR case studies OR cases ) as part of your search. Check out these sample searches:

("case study" OR "case studies" OR cases) AND "organizational behavior"

("case study" OR "case studies" OR cases) AND "strategic management"

("case study" OR "case studies" OR cases) AND "project management"

Also try an Advanced Search  in which you look for case studies in the Subject field, combined with your specific need (entrepreneurship? strategy?) as a Keyword. Add case* in the Title field as well to increase your chance of getting books that contain large numbers of cases. You can also start by  searching for books that have cases in the title AND " case studies" in the subject .

In the SFU Library catalogue, try searching for theses & graduating projects by SFU Business students. Such publications often involve specific case studies. Try searching the catalogue  again, but this time combine the word theses (plural) with your topic. See these sample searches for example theses AND "electronic commerce"  // theses AND "electronic arts" .  Also, try Dissertations and Theses Abstracts and Index  for theses completed elsewhere. See our guide to Finding University Theses and Projects from Simon Fraser and Other Universities for more suggestions.

• In Business Source Complete enter your search terms, then either check off the Document Type Case study or include the Subject Case studies as part of your search.
• CBCA Fulltext Business offers similar ways of finding case studies: either choose the Document Type (click on More Search Options) Case study or include the Subject Case studies as part of your search.
• See the Sample cases area below for some specific journals focusing on business cases.

Websites & databases

Most cases sold by places such as Harvard or the Richard Ivey School of Business are not available via the library. You usually need to pay for the cases if you are not a faculty member, or if you are a faculty member and you want to assign cases in your class. If you are a student and a case has been assigned as a reading in your class, double check with your instructor to see if the case might have been pre-purchased for all members of your class.

Sage Business Cases A global and diverse collection of case studies designed to help students see theoretical business concepts put into practice. This collection is available to all SFU students, instructors, and alumni. See this blog post for further details.

Harvard Business School Cases Harvard's cases are available for direct purchase from the HBR Store .  Qualified and registered instructors  can access Harvard's Educator site to preview cases and access Teaching Notes and other supporting materials. Also see below for a discussion on how to find a small number of HBS cases in the Harvard Business Review.

The Case Centre (formerly the European Case Clearing House) "[T]he largest single source . . . of management case studies in the world. We hold and distribute all cases produced by the world's best-known management teaching establishments, as well as case studies in many languages produced by individual authors from almost every corner of the globe." Search for a case, then click on the link for an "inspection copy" (if available) and follow the links to register as a faculty member.

Richard Ivey School of Business - Cases Faculty can register to preview cases. Note that we have several books in the Ivey Casebook Series .

Cases online via the Harvard Business Review 

Try searching for Harvard Business Review in the Publication Name field in Business Source Complete, then checking the box to limit your search to the Document Type " case study."  Add in other terms to focus your search. 

Note that only a very small subset of all Harvard Business School (HBS) cases are published in the HBR.  The majority of Harvard's business cases are sold only to individuals and classes, not to libraries for use by the entire institution.

Journals that feature case studies

• Journal of Information Technology Teaching Cases : provides "suitable, contemporary case materials for teaching topics in the organisation and management of information systems and on the social consequences of information technology." Note that this is a spin-off journal from the Journal of Information Technology which used to publish such cases. 
• International Journal of Case Studies in Management : Cases from 2003-2012 available via our CBCA database.
• International Journal of Management Cases : The IJMC is the official journal of the CIRCLE Research Centre. CIRCLE (Centre for International Research Consumers, Locations and their Environments) is a virtual research group in over 70 universities.
• Allied Academies International Conference: Proceedings of the International Academy for Case Studies (IACS)
• Journal of the International Academy for Case Studies : Presents classroom teaching cases, with instructor's notes, on any subject which might be taught in a Business School.
• Business Case Journal , Journal of Critical Incidents , and Journal of Case Studies : All from the Society for Case Research
• Asian Case Research Journal : Cases on Asian companies & MNCs operating in Asia-Pacific. No access to the most recent 12 months.
• Journal of Case Research in Business & Economics

Other online sources for cases

• CaseBase & CaseBase2: Case Studies in Global Business : Covers business case studies focused on issues in emerging markets and emerging industries across the globe.
• Business Ethics Case Studies : A few cases from Business Ethics Canada - St. Mary's University
• The Case Centre (formerly the European Case Clearinghouse) offers a selection of free cases .
• Business Gateway : Case studies from Scotland on starting and running a small business.
• The Times 100 : Free business case studies on real life companies. 
• Acadia Institute of Case Studies (Acadia University): Most studies are focused on small business and entrepreneurship and include teaching notes. Some of them even include short videos. Permission is granted for educational use. Note that the AICS site appears to be currently inaccessible, so we've linked to the Web Archive version of their site as of late 2019.
• Company-specific case studies: Intended as examples of how customers have used or could use their products: IBM , Intel , and LANSA .
• Advertising Educational Foundation: Case histories : "Case histories give you an inside look at the steps advertising agencies and advertisers take to create a campaign and how effective it can be. Case histories show the preceding issue/problem, the response and the outcome. Creative is included."
• MarketLine cases in Business Source : Mostly strategic analysis cases featuring large, global companies.
• Open Case Studies : An interdisciplinary collection of cases from UBC that are licensed to allow others to revise and reuse them. Very few of the cases are explicitly categorized as "business," but many of the cases on topics such as Conservation may be useful in a business context.

  An example of case analysis that might give you a sense of what's expected/possible: 

In 1989, the journal Interfaces published an HBS case and asked its readers to submit their analyses. Those analyses were then compiled into two subsequent articles, providing a useful example of the many ways business issues could be viewed and resolved.

Initial case : Porteus, E. L. (1989). The Case Analysis Section: National Cranberry Cooperative . Interfaces, 19 (6), 29–39. https://doi-org.proxy.lib.sfu.ca/10.1287/inte.19.6.29 (Note: this case has been revised multiple times. If it is assigned in your class, make sure you are using the most current revision, mostly likely only available via HBS.)

Analyses:  #1: Porteus, E. L. (1993). Case Analysis: Analyses of the National Cranberry Cooperative -- 1. Tactical Options . Interfaces, 23 (4), 21–39. https://doi-org.proxy.lib.sfu.ca/10.1287/inte.23.4.21

#2: Porteus, E. L. (1993). Case Analysis: Analyses of the National Cranberry Cooperative -- 2. Environmental Changes and Implementation . Interfaces, 23 (6), 81–92. https://doi-org.proxy.lib.sfu.ca/10.1287/inte.23.6.81

• Rotterdam School of Management: CDC Case Writing Training Material Valuable advice to aspiring case writers via a 4-part series in our Sage Business Cases database.
• Why teach with cases? : reflections on philosophy and practice (2022 ebook)
• The ultimate guide to compact cases : case research, writing, and teaching   (2022 ebook)
• Writing, Teaching, and Using Cases : A January 2014 presentation by Leyland Pitt and Michael Parent (both of SFU). Michael and Leyland led a full-day workshop with a focus on case teaching.
• The case writing workbook : a guide for faculty and students : "Designed as an individualized workshop to assist case authors to structure their writing..."
• Guide for Contributors: Tips for Writing Cases : From the publishers of our SAGE Business Cases (SBC) database. Also see the SBC's  Author Guidelines .
• Learning Effectively with Case Studies: A Conversation between a Professor and a Former MBA Student
• The case study companion : teaching, learning and writing business case studies : All angles in one recent (2021) ebook!
• The Case Writer's Toolkit :  "... to help writers visualise concepts, signpost ideas, break down complex information and apply techniques in a practical manner."
• A Brief Guide to Case Teaching : A free guide from The Case Centre
• Teaching with Cases : A Practical Guide : "... focuses on practical advice for instructors that can be easily implemented. It covers how to plan a course, how to teach it, and how to evaluate it."
• Teaching & Authoring Tools : Part of the Ivey Cases site, this page offers documents and videos to help you create your own cases, as well as lists of additional resources.
• Application of a Case Study Methodology by Winston Tellis: (The Qualitative Report, Volume 3, Number 3, September, 1997). This academic article covers the social science methodologies involved in designing, conducting and analysing a case study. It also features a detailed bibliography.
• The Art and Craft of Case Writing (3rd ed. 2012): "[A] practical, comprehensive, and multidisciplinary guide that blends an informal, workshop-style with solid theory and practice." Includes a section on video, multimedia, and Internet cases.
• Basics of Developing Case Studies : Part of the Free Management Library , this site has some basic information on how to develop a case study, as well as links to some sample cases.
• A Guide to Case Analysis : Focus is on how to analyse company cases when learning strategic management techniques. (Depending on your browser settings, you may need to right click this link and open it in a new tab or download it.)
• Case Studies: Overview  (from Cengage): Covers both analysing and writing a case study from the perspective of a business student. From the same publisher: A student's guide to analysing case studies .
• Case Analysis Guide : Developed by a publisher to support students using a Strategic Management text, but applicable in many other situations.
• Short videos on how to approach a case study by the author of the Case Study Handbook: A Student's Guide
• Videos: What is the Case Method? : from The Case Centre

Also, try the subject heading " Case method " in the SFU Library catalogue for books on using the case method in your classes. Suggested sample case method books:

• Encyclopedia of case study research ( print )
• Case study research: design and methods (4th edition, 2009; print )
• Case study research: principles and practices ( online or  print )
• Case writing for executive education: a survival guide ( print )

You might also want to try checking an index of education articles such as ERIC : start with the subject heading (or Descriptor) Case Method (Teaching Technique) .  Alternatively, try our Education Source database using Case method (Teaching) as your subject search term. 

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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity. 

Using our case library

Access to cases.

Many of our cases are available for sale through Harvard Business Publishing in the  Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact  Allison Bodznick , Harvard Chan Case Library administrator, for access.

Access to teaching notes

Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

Access to teaching notes is limited to course instructors only.

• Teaching notes for cases available through  Harvard Business Publishing may be downloaded after registering for an Educator account .
• To request teaching notes for cases that are available for free through this website, look for the "Teaching note  available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

Using the Harvard Business Publishing site

Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website,  where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

What's New

Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country. 

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department.  The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center. 

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods. 

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Johnson, P. & Gordon, R. , 2014. Dr. Sam Thenya: A Women's Health Pioneer , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case tracks Dr. Sam Thenya’s challenges in establishing and sustaining two Kenyan health organizations for women’s health. Thenya founded the Gender Violence Recovery Centre (GVRC) and the Nairobi Women’s Hospital (NWH) Medical Training College. In particular, the case focuses on the choices made as he expanded these two closely connected enterprises even though the GVRC was a non-profit enterprise while the NWH was a for-profit enterprise. Students consider how he led change to improve women’s health at both the population and system levels. They reflect on his leadership and lessons learned as he sought to change the face of women’s health care in Kenya and shift societal attitudes about gender-based violence (GBV). Students analyze how Dr. Thenya scaled up his innovative model, and the subsequent decisions he made to sustain his enterprise. They consider the ways in which he adapted his vision in order to provide GBV services free of charge and expand the reach of these services. This case also provides a Kenyan context in which to discuss health care delivery, and explores general attitudes and issues surrounding GBV.

Gordon, R. & Moon, S. , 2014. Haiti in the Time of Cholera , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case examines the United Nations' reactions to the cholera epidemic in Haiti and illuminates contemporary gaps in global governance. In January, 2010, an earthquake devastated Haiti, the poorest country in the Western Hemisphere. The public health community anticipated Haiti to be at risk for many health threats, but did not consider a cholera outbreak a likely possibility. However, in October of that year, the first case of cholera in more than 100 years was reported, sparking a cholera epidemic in Haiti. Scientific evidence later linked the original source of the cholera to poor sanitation management practices at a United Nations (UN) peacekeepers camp run by Nepal. However, the UN refused to acknowledge any responsibility for causing the cholera outbreak. Readers of this case consider the role of global governance and accountability, especially in an environment with a weak nation state. 

Weinberger, E. , 2015. Weighing the Evidence: One University Takes a Hard Look at Disordered Eating Among Athletes , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Colburn University is the largest private university in the fictitious state of Columbia and is often recognized by people from distant parts of the country for its award-winning Division I athletic teams. That’s why when athletic director Harry Ritchie makes an offhanded comment about Colburn student-athletes with eating disorders, the press pounces. This incident coupled with a complaint from a parent draws the attention of Dean Francis Reilly, who finds himself needing to peel back some of the layers embedding college athletics on the issue of eating disorders among athletes. Throughout the narrative, different perspectives on sports and eating disorders are revealed from top-level administrators, like Dean Reilly, to the student-athletes themselves. As the story concludes, the conversation about eating disorders has begun, but questions still remain on how to make Colburn University a healthy environment for its student-athletes. Intermediate and advanced level teaching notes  available for faculty/instructors .

Weed, L., Lipsitch, M. & Kane, N.M. , 2010. Protecting the Population from the 2009 Pandemic H1N1 Virus , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Download free of charge Abstract Dale Morse, MD, MS, could feel the tension rising in the room. He was chair of a special meeting of the Advisory Committee on Immunization Practices (ACIP) called for July, 2009, that would make recommendations to the Centers for Disease Control (CDC) on whether to prioritize vaccine distribution to protect the population against a possible H1N1 influenza pandemic in the fall.  Dr. Morse was particularly concerned that if ACIP did not set priorities now, he and other state and local public health officials could be faced with a vaccine shortage amid high demand—a situation he described as a potential public health disaster.

Elizabeth, a middle-aged African American woman living in Minnesota, develops chest pain and eventually presents to a local emergency room, where she is diagnosed with stress-related pain and given Vicodin. Members of a non-profit wellness center where she is also seen reflect on the connection between her acute chest pain and underlying stress related to her socioeconomic status. On a larger level, how much of her health is created or controlled by the healthcare system? What non-medical policy decisions impacted Elizabeth such that she is being treated with Vicodin for stress?

Focus on Diversity, Equity, and Inclusion

Weinberger, E. , 2017. Coloring the Narrative: How to Use Storytelling to Create Social Change in Skin Tone Ideals , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Many millions of people around the world experience the pervasive, and often painful, societal messages of colorism, where lighter skin tones are asserted to be more attractive and to reflect greater affluence, power, education, and social status. Even in places where the destructive effects of colorism are fairly well understood, far less is known about the problem of skin-lightening (really, it’s “skin bleaching”) creams and lotions, and the health risks that consumers assume with these products. In this teaching case, the protagonists are two women who have recently immigrated to the United States from Nigeria and Thailand, both with a life-time of experience with these products like many of the women of their home countries. As the story unfolds, they struggle along with the rest of the characters to copy with the push and pull of community norms vs. commercial influences and the challenge of promoting community health in the face of many societal and corporate obstacles. How can the deeply ingrained messages of colorism be effectively confronted and transformed to advance social change without alienating the community members we may most want to reach? Teaching note and supplemental slides available for faculty/instructors .

Al Kasir, A., Coles, E. & Siegrist, R. , 2019. Anchoring Health beyond Clinical Care: UMass Memorial Health Care’s Anchor Mission Project , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract As the Chief Administrative Officer of UMass Memorial Health Care (UMMHC) and president of UMass Memorial (UMM) Community Hospitals, Douglas Brown had just received unanimous and enthusiastic approval to pursue his "Anchor Mission" project at UMMHC in Worcester, Massachusetts. He was extremely excited by the board's support, but also quite apprehensive about how to make the Anchor Mission a reality. Doug had spearheaded the Anchor Mission from its earliest exploratory efforts. The goal of the health system's Anchor Mission-an idea developed by the Democracy Collaborative, an economic think tank-was to address the social determinants of health in its community beyond the traditional approach of providing excellent clinical care. He had argued that UMMHC had an obligation as the largest employer and economic force in Central Massachusetts to consider the broader development of the community and to address non-clinical factors, like homelessness and social inequality that made people unhealthy. To achieve this goal, UMMHC's Anchor Mission would undertake three types of interventions: local hiring, local sourcing/purchasing, and place-based community investment projects. While the board's enthusiasm was palpable and inspiring, Doug knew that sustaining it would require concrete accomplishments and a positive return on any investments the health system made in the project. The approval was just the first step. Innovation and new ways of thinking would be necessary. The bureaucracy behind a multi-billion-dollar healthcare organization would need to change. Even the doctors and nurses would need to change! He knew that the project had enormous potential but would become even more daunting from here.

This teaching case study examines psychological trauma in a community context and the relevance, both positive and negative, of social determinants of health. Healthy People 2020 views people residing in communities with large-scale psychological trauma as an emerging issue in mental health and mental health disorders (Healthy People, 2016). The case study, which focuses on Newark, New Jersey, addresses three of the five key determinants of health: social and community context, health and health care, and neighborhood and built environment. The three key determinants are addressed using psychological trauma as an exemplar in the context of trauma-informed systems. The social and community context is addressed using concepts of social cohesion, civic participation, and discrimination. Access to health and health care are addressed with discussion of access to mental health and primary care services, health literacy, and the medical home model. Neighborhood and built environment are viewed through the lens of available government and NGO programs and resources to improve the physical environment with a focus on quality of housing, crime and violence, and environmental conditions. Upstream interventions designed to improve mental health and well-being that support trauma-informed systems are analyzed. The use of Newark as the case study setting allows a real-life exploration of each of these three key determinants of health.

This case study has four sections – introduction, case study, side bar, and vignettes. Learners should work through the case, access appropriate resources, and work in a team for successful completion.

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

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Browse our case library

Datar, S.M., Cyr, L. & Bowler, C.N. , 2018. Innovation at Insigne Health , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Insigne Health is a for-profit, integrated health insurer/health care provider whose leadership believes that by shifting members' focus from "sickness" to "well-being" it could increase the overall health of its insured population and decrease the resources it spends each year on delivering care. The case puts students in the role of design researcher charged with understanding the member segment about which Insigne Health leadership is most concerned: The "silent middle." This cohort represents 70% of membership and is "neither sick nor well." Without changes in a range of behaviors, these members may be quietly developing conditions that will evolve into costly chronic diseases. From interviews included in the case, students uncover insights into member behavior and, based on these insights, generate and develop concepts to help members change behaviors and lead healthier lives.

Cash, R., et al. , 2009. Casebook on ethical issues in international health research , World Health Organization. Publisher's Version Abstract This casebook published by the World Health Organization contains 64 case studies, each of which raises an important and difficult ethical issue connected with planning, reviewing, or conducting health-related research. Available for download free of charge from the World Health Organization in English, Arabic, Russian, and Spanish.

When Dr. Marwan started as director of Ramses Hospital in Cairo in 2008, charged by the Minister of Health with improving performance, he found the hospital had been neglected for decades. A Ministry of Health quality audit had recently given the hospital the worst score of the five hospitals designated as critical to the greater Cairo area. 

Dr. Marwan vowed that Ramses Hospital would come in first in the next round of quality audits. Without improving its quality scores, the hospital would be unable to pass the accreditation process required for hospital participation in a new universal social health insurance scheme. In addition—and just as critically—Dr. Marwan needed to develop a longer-term strategy for obtaining the considerable additional resources required to upgrade the long-neglected facility.

Quelch, J.A. & Rodriguez, M. , 2015. Carolinas HealthCare System: Consumer Analytics , Harvard Business Publishing. Available from Harvard Business Publishing Abstract In 2014, Dr. Michael Dulin, chief clinical officer for analytics and outcomes research and head of the Dickson Advanced Analytics (DA2) group at Carolinas HealthCare System (CHS), successfully unified all analytics talent and resources into one group over a three year period. Rapid increases in computing power and decreases in data storage costs had enabled DA2's data architects to build predictive models incorporating complex clinical, financial, demographic, and claims data that would have been impossible to create only a few years before. However, in 2014, both Apple and Google announced features in their new mobile operating systems that collected and displayed output from various health-wearables (like heart-rate monitors or step-counters), as well as electronic medical record (EMR) data. Their expertise in analytics, access to demographic and location data, as well as large consumer bases, led Dulin to consider which players consumers would trust to integrate their healthcare data in the future and what role DA2 could play.

Guerra, I., et al. , 2019. SALUDos: Healthcare for Migrant Seasonal Farm Workers , Harvard University: Social Medicine Consortium. Download free of charge Abstract The SALUDos program began in 2008 as a response to an influx of migrant seasonal farm workers (MSFWs) at a mobile medical unit serving homeless persons in Santa Clara County in Northern California. The program offered patients free and low-cost primary care services, linkage to resources, and advocacy.  As the farm workers involved in this program became more involved in their primary care, they advocated for evening hours, transportation, linkage to coverage programs, and health education resources to better understand their medical and psychological conditions. During continual modifications of the SALUDos program, the team sought to understand and address large-scale social forces affecting migrant health through interventions to mitigate health inequities. Teaching note available for faculty/instructors.

Weinberger, E. , 2015. Full of Surprises: Dietary Supplements and the Gym, or, a Tale of Corporate Social Responsibility , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Working out at the gym is a healthy endeavor, but many gyms endorse unhealthful practices. They may advertise or sell dietary supplements for weight loss or muscle building that not only fail to do what they promise, but contain potentially dangerous ingredients. Callie Guertin is a primary care physician in Hamilton, in the fictitious U.S. state of Columbia, and a daily gym-goer who is slowly awakening to the fact that her chosen new gym, MuscleTone, sells weight-loss supplements at its welcome desk. She wants them to stop; but what can she do on her own? With some guidance from a young activist, Stacie Lubin, and her sympathetic personal trainer, Rudi, Guertin learns skills of coalition building to pressure the MuscleTone chain to change its practices. Perhaps, using principles of corporate social responsibility, or CSR, MuscleTone can be made to realize that abandoning sales and advertising of supplements can produce a good result for everybody—healthier customers, of course, but also a new marketing campaign touting MuscleTone as the gym for “healthy living”? Guertin and her allies are working on MuscleTone to make just this case. Teaching note available for faculty/instructors .

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Where Can I find Harvard Business School Case Studies?

How do i find articles with case studies, where can i find free case studies, subject specialists.

Harvard Business Publishing makes a great deal of money selling these for business school course packs and will not make them available to libraries. You can, however, order them directly from HBS, around $8.95 each How to find them:

• Harvard Business Review publishes one case study per issue. These generally deal with fictitious companies but are very good studies of current problems faced by companies.
• Harvard Business School Publishing Search by company name or topic. Abstracts are usually included. Harvard also sells cases from Babson College and Northwestern's Kellogg School of Management, among others.

Use keyword searches in article databases . For example: "case studies and airlines" or "case  studies and management". Full-text articles and abstracts are available, depending on the journal.

Tip: Use the subject heading "case studies" in ABI/INFORM and Business Source Complete

Article database that indexes academic journals, trade publications, newspapers and magazines in business and economics. Full text is often available. Use the FindIt links to locate full text of articles that are not included in the database.

• Business Source Complete This link opens in a new window & more less... Article database that includes trade publications, academic journals, industry profiles, country information and company profiles, which include SWOT analyses. Full text is often available. Use the FindIt links to locate full text of articles that are not included in the database.
• EconLit with Full Text This link opens in a new window & more less... EconLit indexes articles from economics journals, books, book chapters, dissertations and working papers. It is a very good source for empirical studies on economics and finance. Use the FindIt links to locate full text of articles that are not included in the database.

Most cases published for teaching in business schools are not free to use. These are a few resources that do offer free cases, but only LearningEdge offers their entire catalog for free.

• LearningEdge Cases developed at the MIT Sloan School of Management.
• Free cases from Stanford Graduate School of Business More are available for purchase through Harvard Business School Publishing
• Free cases from the Case Centre A selection of cases. Many more available for purchase
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HBS Case Selections

Innovation at Moog Inc.

• Brian J. Hall
• Ashley V. Whillans
• Davis Heniford
• Dominika Randle
• Caroline Witten

Innovation at Google Ads: The Sales Acceleration and Innovation Labs (SAIL) (A)

• Linda A. Hill
• Emily Tedards

Juan Valdez: Innovation in Caffeination

• Michael I. Norton
• Jeremy Dann

UGG Steps into the Metaverse

• Shunyuan Zhang
• Sharon Joseph
• Sunil Gupta
• Julia Kelley

Metaverse Wars

• David B. Yoffie
• Matt Higgins

Roblox: Virtual Commerce in the Metaverse

• Ayelet Israeli
• Nicole Tempest Keller

Timnit Gebru: "SILENCED No More" on AI Bias and The Harms of Large Language Models

• Tsedal Neeley
• Stefani Ruper

Hugging Face: Serving AI on a Platform

• Shane Greenstein
• Kerry Herman
• Sarah Gulick

SmartOne: Building an AI Data Business

• Karim R. Lakhani
• Pippa Tubman Armerding
• Gamze Yucaoglu
• Fares Khrais

Honeywell and the Great Recession (A)

• Sandra J. Sucher
• Susan Winterberg

Target: Responding to the Recession

• Ranjay Gulati
• Catherine Ross
• Richard S. Ruback
• Royce Yudkoff

Hometown Foods: Changing Price Amid Inflation

• Julian De Freitas
• Jeremy Yang
• Das Narayandas

Elon Musk's Big Bets

• Eric Baldwin

Elon Musk: Balancing Purpose and Risk

• Shikhar Ghosh
• Sarah Mehta

Tesla's CEO Compensation Plan

• Krishna G. Palepu
• John R. Wells
• Gabriel Ellsworth

China Rapid Finance: The Collapse of China's P2P Lending Industry

• William C. Kirby
• Bonnie Yining Cao
• John P. McHugh

Forbidden City: Launching a Craft Beer in China

• Christopher A. Bartlett
• Carole Carlson

Booking.com

• Stefan Thomke
• Daniela Beyersdorfer

Innovation at Uber: The Launch of Express POOL

• Chiara Farronato
• Alan MacCormack

Racial Discrimination on Airbnb (A)

• Michael Luca
• Scott Stern
• Hyunjin Kim

GitLab and the Future of All-Remote Work (A)

• Prithwiraj Choudhury
• Emma Salomon

TCS: From Physical Offices to Borderless Work

Creating a virtual internship at goldman sachs.

• Iavor Bojinov

Unilever's Response to the Future of Work

• William R. Kerr
• Emilie Billaud
• Mette Fuglsang Hjortshoej

AT&T, Retraining, and the Workforce of Tomorrow

• Joseph B. Fuller
• Carl Kreitzberg

Leading Change in Talent at L'Oreal

• Lakshmi Ramarajan
• Vincent Dessain
• Emer Moloney
• William W. George
• Andrew N. McLean

Eve Hall: The African American Investment Fund in Milwaukee

• Steven S. Rogers
• Alterrell Mills

United Housing - Otis Gates

• Mercer Cook

The Home Depot: Leadership in Crisis Management

• Herman B. Leonard
• Marc J. Epstein
• Melissa Tritter

The Great East Japan Earthquake (B): Fast Retailing Group's Response

• Hirotaka Takeuchi
• Kenichi Nonomura
• Dena Neuenschwander
• Meghan Ricci
• Kate Schoch
• Sergey Vartanov

Insurer of Last Resort?: The Federal Financial Response to September 11

• David A. Moss
• Sarah Brennan

Under Armour

• Rory McDonald
• Clayton M. Christensen
• Daniel West
• Jonathan E. Palmer
• Tonia Junker

Hunley, Inc.: Casting for Growth

• John A. Quelch
• James T. Kindley

Bitfury: Blockchain for Government

• Mitchell B. Weiss
• Elena Corsi

Deutsche Bank: Pursuing Blockchain Opportunities (A)

• Lynda M. Applegate
• Christoph Muller-Bloch

Maersk: Betting on Blockchain

• Scott Johnson

Yum! Brands

• Jordan Siegel
• Christopher Poliquin

Bharti Airtel in Africa

• Tanya Bijlani

Li & Fung 2012

• F. Warren McFarlan
• Michael Shih-ta Chen
• Keith Chi-ho Wong

Sony and the JK Wedding Dance

• John Deighton
• Leora Kornfeld

United Breaks Guitars

David dao on united airlines.

• Benjamin Edelman
• Jenny Sanford

Marketing Reading: Digital Marketing

• Joseph Davin

Social Strategy at Nike

• Mikolaj Jan Piskorski
• Ryan Johnson

The Tate's Digital Transformation

Social strategy at american express, mellon financial and the bank of new york.

• Carliss Y. Baldwin
• Ryan D. Taliaferro

The Walt Disney Company and Pixar, Inc.: To Acquire or Not to Acquire?

• Juan Alcacer
• David J. Collis

Dow's Bid for Rohm and Haas

• Benjamin C. Esty

Finance Reading: The Mergers and Acquisitions Process

• John Coates

Apple: Privacy vs. Safety? (A)

• Henry W. McGee
• Nien-he Hsieh
• Sarah McAra

Sidewalk Labs: Privacy in a City Built from the Internet Up

• Leslie K. John

Data Breach at Equifax

• Suraj Srinivasan
• Quinn Pitcher
• Jonah S. Goldberg

Apple's Core

• Noam Wasserman

Design Thinking and Innovation at Apple

• Barbara Feinberg

Apple Inc. in 2012

• Penelope Rossano

Iz-Lynn Chan at Far East Organization (Abridged)

• Anthony J. Mayo
• Dana M. Teppert

Barbara Norris: Leading Change in the General Surgery Unit

• Boris Groysberg
• Nitin Nohria
• Deborah Bell

Adobe Systems: Working Towards a "Suite" Release (A)

• David A. Thomas
• Lauren Barley
• Jan W. Rivkin

Starbucks Coffee Company: Transformation and Renewal

• Nancy F. Koehn
• Kelly McNamara
• Nora N. Khan
• Elizabeth Legris

JCPenney: Back in Business

• K. Shelette Stewart
• Christine Snively

Home Nursing of North Carolina

Castronics, llc, gemini investors, angie's list: ratings pioneer turns 20.

• Robert J. Dolan

Basecamp: Pricing

• Frank V. Cespedes
• Robb Fitzsimmons

J.C. Penney's "Fair and Square" Pricing Strategy

J.c. penney's 'fair and square' strategy (c): back to the future.

• Jose B. Alvarez

Osaro: Picking the best path

• James Palano
• Bastiane Huang

HubSpot and Motion AI: Chatbot-Enabled CRM

• Thomas Steenburgh

GROW: Using Artificial Intelligence to Screen Human Intelligence

• Ethan S. Bernstein
• Paul D. McKinnon
• Paul Yarabe

Arup: Building the Water Cube

• Robert G. Eccles
• Amy C. Edmondson
• Dilyana Karadzhova

(Re)Building a Global Team: Tariq Khan at Tek

Managing a global team: greg james at sun microsystems, inc. (a).

• Thomas J. DeLong

Organizational Behavior Reading: Leading Global Teams

Ron ventura at mitchell memorial hospital.

• Heide Abelli

Anthony Starks at InSiL Therapeutics (A)

• Gary P. Pisano
• Vicki L. Sato

Wolfgang Keller at Konigsbrau-TAK (A)

• John J. Gabarro

The 2010 Chilean Mining Rescue (A)

• Faaiza Rashid

IDEO: Human-Centered Service Design

• Ryan W. Buell
• Andrew Otazo
• Benjamin Jones
• Alexis Brownell

David Neeleman: Flight Path of a Servant Leader (A)

• Matthew D. Breitfelder

Coach Hurley at St. Anthony High School

• Scott A. Snook
• Bradley C. Lawrence

Shapiro Global

• Michael Brookshire
• Monica Haugen
• Michelle Kravetz
• Sarah Sommer

Kathryn McNeil (A)

• Joseph L. Badaracco Jr.
• Jerry Useem

Carol Fishman Cohen: Professional Career Reentry (A)

• Myra M. Hart
• Robin J. Ely
• Susan Wojewoda

Alex Montana at ESH Manufacturing Co.

• Michael Kernish

Michelle Levene (A)

• Tiziana Casciaro
• Victoria W. Winston

John and Andrea Rice: Entrepreneurship and Life

• Howard H. Stevenson
• Janet Kraus
• Shirley M. Spence

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The following databases contain filters specifically for finding case studies. Keep in mind that in many databases and search tools, adding the phrase "case study" to your search terms can also help you find case studies.

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• Computer Science Database This link opens in a new window This collection provides unmatched discipline-specific coverage spanning thousands of publications, many in full text. Subject coverage: Computer Science; Information Systems; Computer Security; Database Design; Software Development; Web Commerce; LANs; WANs; Intranets; Internet. To find case studies, go to the Advanced Search page , go to the box labeled "Document Type," and select "Case Study."
• Emerald Emerging Markets Case Studies Collection This link opens in a new window Emerald Emerging Markets Case Studies (EEMCS) is an online collection of peer-reviewed case studies focusing on business decision making and management development throughout key global emerging markets . Cases are written by case writers working in or closely with developing economies, offering local perspectives with global appeal.
• ProQuest One Business This link opens in a new window An intuitive and comprehensive business library containing millions of full-text items across scholarly and popular periodicals, newspapers, market research reports, dissertations, books, videos and more. To find case studies, go to the Advanced Search page , go to the box labeled "Document Type," and select "Case Study."
• SAGE Journals This link opens in a new window Access more than 650 journals spanning the Humanities, Social Sciences, and Science, Technology, and Medicine. To find case studies, enter your search terms. On the search results page, go to the Article Type filter on the right and select Case Report. Note: you may need to click "More" under Article Type, and you may then need to search for "Case Report" under the Article Type filters.
• Science Database This link opens in a new window Subject areas include: • Physics • Engineering • Astronomy • Biology • Earth Science • Chemistry • and more. To find case studies, go to the Advanced Search page , go to the box labeled "Document Type," and select "Case Study."
• SciTech Premium Collection This link opens in a new window Subject areas include: • Advanced technologies • Aerospace • Agricultural science • Aquatic science • Atmospheric science • Biological science • Computer science • Earth science • Environmental science • Engineering • Materials science • Polymer science. To find case studies, go to the Advanced Search page , go to the box labeled "Document Type," and select "Case Study."
• Technology Collection This link opens in a new window The Technology Collection provides broad indexing coverage of the scholarly literature in advanced technology, computer science, engineering, materials science and related areas. To find case studies, go to the Advanced Search page , go to the box labeled "Document Type," and select "Case Study."
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Case Studies

More than 70 cases pair ethics concepts with real world situations. From journalism, performing arts, and scientific research to sports, law, and business, these case studies explore current and historic ethical dilemmas, their motivating biases, and their consequences. Each case includes discussion questions, related videos, and a bibliography.

A Million Little Pieces

James Frey’s popular memoir stirred controversy and media attention after it was revealed to contain numerous exaggerations and fabrications.

Abramoff: Lobbying Congress

Super-lobbyist Abramoff was caught in a scheme to lobby against his own clients. Was a corrupt individual or a corrupt system – or both – to blame?

Apple Suppliers & Labor Practices

Is tech company Apple, Inc. ethically obligated to oversee the questionable working conditions of other companies further down their supply chain?

Approaching the Presidency: Roosevelt & Taft

Some presidents view their responsibilities in strictly legal terms, others according to duty. Roosevelt and Taft took two extreme approaches.

Appropriating “Hope”

Fairey’s portrait of Barack Obama raised debate over the extent to which an artist can use and modify another’s artistic work, yet still call it one’s own.

Arctic Offshore Drilling

Competing groups frame the debate over oil drilling off Alaska’s coast in varying ways depending on their environmental and economic interests.

Banning Burkas: Freedom or Discrimination?

The French law banning women from wearing burkas in public sparked debate about discrimination and freedom of religion.

Birthing Vaccine Skepticism

Wakefield published an article riddled with inaccuracies and conflicts of interest that created significant vaccine hesitancy regarding the MMR vaccine.

Blurred Lines of Copyright

Marvin Gaye’s Estate won a lawsuit against Robin Thicke and Pharrell Williams for the hit song “Blurred Lines,” which had a similar feel to one of his songs.

Bullfighting: Art or Not?

Bullfighting has been a prominent cultural and artistic event for centuries, but in recent decades it has faced increasing criticism for animal rights’ abuse.

Buying Green: Consumer Behavior

Do purchasing green products, such as organic foods and electric cars, give consumers the moral license to indulge in unethical behavior?

Cadavers in Car Safety Research

Engineers at Heidelberg University insist that the use of human cadavers in car safety research is ethical because their research can save lives.

Cardinals’ Computer Hacking

St. Louis Cardinals scouting director Chris Correa hacked into the Houston Astros’ webmail system, leading to legal repercussions and a lifetime ban from MLB.

Cheating: Atlanta’s School Scandal

Teachers and administrators at Parks Middle School adjust struggling students’ test scores in an effort to save their school from closure.

Cheating: Sign-Stealing in MLB

The Houston Astros’ sign-stealing scheme rocked the baseball world, leading to a game-changing MLB investigation and fallout.

Cheating: UNC’s Academic Fraud

UNC’s academic fraud scandal uncovered an 18-year scheme of unchecked coursework and fraudulent classes that enabled student-athletes to play sports.

Cheney v. U.S. District Court

A controversial case focuses on Justice Scalia’s personal friendship with Vice President Cheney and the possible conflict of interest it poses to the case.

Christina Fallin: “Appropriate Culturation?”

After Fallin posted a picture of herself wearing a Plain’s headdress on social media, uproar emerged over cultural appropriation and Fallin’s intentions.

Climate Change & the Paris Deal

While climate change poses many abstract problems, the actions (or inactions) of today’s populations will have tangible effects on future generations.

Cover-Up on Campus

While the Baylor University football team was winning on the field, university officials failed to take action when allegations of sexual assault by student athletes emerged.

Covering Female Athletes

Sports Illustrated stirs controversy when their cover photo of an Olympic skier seems to focus more on her physical appearance than her athletic abilities.

Covering Yourself? Journalists and the Bowl Championship

Can news outlets covering the Bowl Championship Series fairly report sports news if their own polls were used to create the news?

Cyber Harassment

After a student defames a middle school teacher on social media, the teacher confronts the student in class and posts a video of the confrontation online.

Defending Freedom of Tweets?

Running back Rashard Mendenhall receives backlash from fans after criticizing the celebration of the assassination of Osama Bin Laden in a tweet.

Dennis Kozlowski: Living Large

Dennis Kozlowski was an effective leader for Tyco in his first few years as CEO, but eventually faced criminal charges over his use of company assets.

Digital Downloads

File-sharing program Napster sparked debate over the legal and ethical dimensions of downloading unauthorized copies of copyrighted music.

Dr. V’s Magical Putter

Journalist Caleb Hannan outed Dr. V as a trans woman, sparking debate over the ethics of Hannan’s reporting, as well its role in Dr. V’s suicide.

East Germany’s Doping Machine

From 1968 to the late 1980s, East Germany (GDR) doped some 9,000 athletes to gain success in international athletic competitions despite being aware of the unfortunate side effects.

Ebola & American Intervention

Did the dispatch of U.S. military units to Liberia to aid in humanitarian relief during the Ebola epidemic help or hinder the process?

Edward Snowden: Traitor or Hero?

Was Edward Snowden’s release of confidential government documents ethically justifiable?

Ethical Pitfalls in Action

Why do good people do bad things? Behavioral ethics is the science of moral decision-making, which explores why and how people make the ethical (and unethical) decisions that they do.

Ethical Use of Home DNA Testing

The rising popularity of at-home DNA testing kits raises questions about privacy and consumer rights.

Flying the Confederate Flag

A heated debate ensues over whether or not the Confederate flag should be removed from the South Carolina State House grounds.

Freedom of Speech on Campus

In the wake of racially motivated offenses, student protests sparked debate over the roles of free speech, deliberation, and tolerance on campus.

Freedom vs. Duty in Clinical Social Work

What should social workers do when their personal values come in conflict with the clients they are meant to serve?

Full Disclosure: Manipulating Donors

When an intern witnesses a donor making a large gift to a non-profit organization under misleading circumstances, she struggles with what to do.

Gaming the System: The VA Scandal

The Veterans Administration’s incentives were meant to spur more efficient and productive healthcare, but not all administrators complied as intended.

German Police Battalion 101

During the Holocaust, ordinary Germans became willing killers even though they could have opted out from murdering their Jewish neighbors.

Head Injuries & American Football

Many studies have linked traumatic brain injuries and related conditions to American football, creating controversy around the safety of the sport.

Head Injuries & the NFL

American football is a rough and dangerous game and its impact on the players’ brain health has sparked a hotly contested debate.

Healthcare Obligations: Personal vs. Institutional

A medical doctor must make a difficult decision when informing patients of the effectiveness of flu shots while upholding institutional recommendations.

High Stakes Testing

In the wake of the No Child Left Behind Act, parents, teachers, and school administrators take different positions on how to assess student achievement.

In-FUR-mercials: Advertising & Adoption

When the Lied Animal Shelter faces a spike in animal intake, an advertising agency uses its moral imagination to increase pet adoptions.

Krogh & the Watergate Scandal

Egil Krogh was a young lawyer working for the Nixon Administration whose ethics faded from view when asked to play a part in the Watergate break-in.

Limbaugh on Drug Addiction

Radio talk show host Rush Limbaugh argued that drug abuse was a choice, not a disease. He later became addicted to painkillers.

U.S. Olympic swimmer Ryan Lochte’s “over-exaggeration” of an incident at the 2016 Rio Olympics led to very real consequences.

Meet Me at Starbucks

Two black men were arrested after an employee called the police on them, prompting Starbucks to implement “racial-bias” training across all its stores.

Myanmar Amber

Buying amber could potentially fund an ethnic civil war, but refraining allows collectors to acquire important specimens that could be used for research.

Negotiating Bankruptcy

Bankruptcy lawyer Gellene successfully represented a mining company during a major reorganization, but failed to disclose potential conflicts of interest.

Pao & Gender Bias

Ellen Pao stirred debate in the venture capital and tech industries when she filed a lawsuit against her employer on grounds of gender discrimination.

Pardoning Nixon

One month after Richard Nixon resigned from the presidency, Gerald Ford made the controversial decision to issue Nixon a full pardon.

Patient Autonomy & Informed Consent

Nursing staff and family members struggle with informed consent when taking care of a patient who has been deemed legally incompetent.

Prenatal Diagnosis & Parental Choice

Debate has emerged over the ethics of prenatal diagnosis and reproductive freedom in instances where testing has revealed genetic abnormalities.

Reporting on Robin Williams

After Robin Williams took his own life, news media covered the story in great detail, leading many to argue that such reporting violated the family’s privacy.

Responding to Child Migration

An influx of children migrants posed logistical and ethical dilemmas for U.S. authorities while intensifying ongoing debate about immigration.

Retracting Research: The Case of Chandok v. Klessig

A researcher makes the difficult decision to retract a published, peer-reviewed article after the original research results cannot be reproduced.

Sacking Social Media in College Sports

In the wake of questionable social media use by college athletes, the head coach at University of South Carolina bans his players from using Twitter.

Selling Enron

Following the deregulation of electricity markets in California, private energy company Enron profited greatly, but at a dire cost.

Snyder v. Phelps

Freedom of speech was put on trial in a case involving the Westboro Baptist Church and their protesting at the funeral of U.S. Marine Matthew Snyder.

Something Fishy at the Paralympics

Rampant cheating has plagued the Paralympics over the years, compromising the credibility and sportsmanship of Paralympian athletes.

Sports Blogs: The Wild West of Sports Journalism?

Deadspin pays an anonymous source for information related to NFL star Brett Favre, sparking debate over the ethics of “checkbook journalism.”

Stangl & the Holocaust

Franz Stangl was the most effective Nazi administrator in Poland, killing nearly one million Jews at Treblinka, but he claimed he was simply following orders.

Teaching Blackface: A Lesson on Stereotypes

A teacher was put on leave for showing a blackface video during a lesson on racial segregation, sparking discussion over how to teach about stereotypes.

The Astros’ Sign-Stealing Scandal

The Houston Astros rode a wave of success, culminating in a World Series win, but it all came crashing down when their sign-stealing scheme was revealed.

The Central Park Five

Despite the indisputable and overwhelming evidence of the innocence of the Central Park Five, some involved in the case refuse to believe it.

The CIA Leak

Legal and political fallout follows from the leak of classified information that led to the identification of CIA agent Valerie Plame.

The Collapse of Barings Bank

When faced with growing losses, investment banker Nick Leeson took big risks in an attempt to get out from under the losses. He lost.

The Costco Model

How can companies promote positive treatment of employees and benefit from leading with the best practices? Costco offers a model.

The FBI & Apple Security vs. Privacy

How can tech companies and government organizations strike a balance between maintaining national security and protecting user privacy?

The Miss Saigon Controversy

When a white actor was cast for the half-French, half-Vietnamese character in the Broadway production of Miss Saigon , debate ensued.

The Sandusky Scandal

Following the conviction of assistant coach Jerry Sandusky for sexual abuse, debate continues on how much university officials and head coach Joe Paterno knew of the crimes.

The Varsity Blues Scandal

A college admissions prep advisor told wealthy parents that while there were front doors into universities and back doors, he had created a side door that was worth exploring.

Providing radiation therapy to cancer patients, Therac-25 had malfunctions that resulted in 6 deaths. Who is accountable when technology causes harm?

Welfare Reform

The Welfare Reform Act changed how welfare operated, intensifying debate over the government’s role in supporting the poor through direct aid.

Wells Fargo and Moral Emotions

In a settlement with regulators, Wells Fargo Bank admitted that it had created as many as two million accounts for customers without their permission.

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Methodology

• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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US Case Law

The United States Supreme Court is the highest court in the United States. Lower courts on the federal level include the US Courts of Appeals, US District Courts, the US Court of Claims, and the US Court of International Trade and US Bankruptcy Courts. Federal courts hear cases involving matters related to the United States Constitution, other federal laws and regulations, and certain matters that involve parties from different states or countries and large sums of money in dispute.

Each state has its own judicial system that includes trial and appellate courts. The highest court in each state is often referred to as the “supreme” court, although there are some exceptions to this rule, for example, the New York Court of Appeals or the Maryland Court of Appeals. State courts generally hear cases involving state constitutional matters, state law and regulations, although state courts may also generally hear cases involving federal laws. States also usually have courts that handle only a specific subset of legal matters, such as family law and probate.

Case law, also known as precedent or common law, is the body of prior judicial decisions that guide judges deciding issues before them. Depending on the relationship between the deciding court and the precedent, case law may be binding or merely persuasive. For example, a decision by the US Court of Appeals for the Fifth Circuit is binding on all federal district courts within the Fifth Circuit, but a court sitting in California (whether a federal or state court) is not strictly bound to follow the Fifth Circuit’s prior decision. Similarly, a decision by one district court in New York is not binding on another district court, but the original court’s reasoning might help guide the second court in reaching its decision.

Decisions by the US Supreme Court are binding on all federal and state courts.

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• Bankruptcy Reporter (B.R.) (1980-present)
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Center for Teaching

Case studies.

Print Version

Case studies are stories that are used as a teaching tool to show the application of a theory or concept to real situations. Dependent on the goal they are meant to fulfill, cases can be fact-driven and deductive where there is a correct answer, or they can be context driven where multiple solutions are possible. Various disciplines have employed case studies, including humanities, social sciences, sciences, engineering, law, business, and medicine. Good cases generally have the following features: they tell a good story, are recent, include dialogue, create empathy with the main characters, are relevant to the reader, serve a teaching function, require a dilemma to be solved, and have generality.

Instructors can create their own cases or can find cases that already exist. The following are some things to keep in mind when creating a case:

• What do you want students to learn from the discussion of the case?
• What do they already know that applies to the case?
• What are the issues that may be raised in discussion?
• How will the case and discussion be introduced?
• What preparation is expected of students? (Do they need to read the case ahead of time? Do research? Write anything?)
• What directions do you need to provide students regarding what they are supposed to do and accomplish?
• Do you need to divide students into groups or will they discuss as the whole class?
• Are you going to use role-playing or facilitators or record keepers? If so, how?
• What are the opening questions?
• How much time is needed for students to discuss the case?
• What concepts are to be applied/extracted during the discussion?
• How will you evaluate students?

To find other cases that already exist, try the following websites:

• The National Center for Case Study Teaching in Science , University of Buffalo. SUNY-Buffalo maintains this set of links to other case studies on the web in disciplines ranging from engineering and ethics to sociology and business
• A Journal of Teaching Cases in Public Administration and Public Policy , University of Washington

For more information:

• World Association for Case Method Research and Application

Book Review :  Teaching and the Case Method , 3rd ed., vols. 1 and 2, by Louis Barnes, C. Roland (Chris) Christensen, and Abby Hansen. Harvard Business School Press, 1994; 333 pp. (vol 1), 412 pp. (vol 2).

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Organizing Your Social Sciences Research Assignments

• Annotated Bibliography
• Analyzing a Scholarly Journal Article
• Group Presentations
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• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
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• Multiple Book Review Essay
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• Writing a Case Analysis Paper
• Writing a Case Study
• About Informed Consent
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• Writing a Reflective Paper
• Writing a Research Proposal
• Generative AI and Writing
• Acknowledgments

A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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Case studies.

• Introduction

Finding case studies from the Library

Finding case studies on the web.

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LibrarySearch

LibrarySearch is one place to start when looking for case studies.  You can find specialised case study journals, books that include case studies, and articles based on case studies.

Search tips

LibrarySearch does not include Case Study as a resource type. Try using the following search terms (including the inverted commas):  

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Within databases you can often find case studies in journals aimed at academic or professional audiences.

• Check the Advanced Search options to see if you can filter your search by Case Study or Case Studies.  This might be under Document Type or Subjects.
• In the search results list look for options to refine by Case Study.  This might be to the right or left of the results.
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YouTube videos include material from experts and non-experts on any subject you care to name.

• Add 'case study' to your search.
• To better filter video content use the main Google search options to search for Videos.  This will return video content hosted by YouTube and elsewhere.
• You can use Advanced Search via the quick settings in top right corner of search screen and the same Google search tips listed above when searching for videos.

A Google search will find case studies in a variety of formats such as government reports, academic articles and websites.  

Use Advanced Search (under Settings) to target your search.

• Use Region and/or Last Update to filter a specific country and/or time.
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• Access Google Scholar from the  Library homepage  to link through to Library subscribed resources.
• Add "case study", "case studies" or "case report" to your search terms.

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A case study is an in-depth look or detailed examination of a particular event, scenario, or group. Case studies are extremely popular teaching tools in the field of management, as they help students apply course topics to real-world scenarios. Case studies come in a variety of formats (articles, book chapters, videos, etc.). Learn how to find case studies in the library collection below. 

Note:   We have several collections with case studies (as seen below), but they can still be hard to find. Many companies pay experts to write case studies and, in turn, want payment for the cases. 

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Case Studies in Book Chapters

Some of the best case studies can be found in books on leadership and management. The best way to search for books that have case studies is to combine your search term(s) with the keyword “case study” and filter to Content Type > Book Chapter (on left-hand side of the search results screen). 

Here is an example search: "case study" AND organizational culture  

Select CityU Journals with Business Cases

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• Enter your search words the in the top section titled  Find web pages with… 
• Near the bottom, enter domain code in the box labeled  Search within a site or domain 
• Click the  Advanced Search  button to see the results 

Example search by country domain code:  “aerospace case study”  in the United Kingdom 

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• Published: 02 April 2024

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

• Brit Torunn Bechensteen 1 , 2 ,
• Cindhya Sithiravel 3 ,
• Ellen Marie Strøm-Roum 4 ,
• Heidi Kathrine Ruud 2 ,
• Gunnhild Kravdal 3 ,
• Jacob A. Winther 1 &
• Tone G. Valderhaug 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  229 ( 2024 ) Cite this article

135 Accesses

Metrics details

Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.

In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n  = 59 [gastric bypass surgery n  = 26, sleeve gastrectomy n  = 31, missing n  = 2] and controls n  = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).

The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p  < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p  = 0.228) or development of gestational diabetes ( n  = 3 [5%] vs. n  = 7 [5%], p  = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p  < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p  = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p  = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p  = 0.030).

Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Peer Review reports

Obesity is common in women of reproductive age, increasing the risk of several complications for mother and child [ 1 , 2 ]. Maternal metabolism in obesity may reduce the likelihood of successful pregnancy [ 3 ]. Moreover, given that weight loss before pregnancy mitigates the adverse outcomes of pregnancy related outcomes from obesity, bariatric surgery in women of reproductive age in increasing [ 4 , 5 ]. However, although bariatric surgery may reduce the risks of certain obesity related complications in pregnancy, pregnancy after bariatric surgery may carry adverse events such as malnutrition, vitamin deficiencies and inadequate weight gain as well as changes in endocrine and metabolic homeostasis [ 6 , 7 , 8 , 9 , 10 ]. Pregnancy following bariatric surgery has been associated with increased risk of preterm birth, nutritional deficiency and small for gestational age [ 7 , 8 , 11 , 12 , 13 , 14 ]. The causality of these effects are not known, but personalized nutritional counseling during post-bariatric pregnancy has been shown to improve nutrient intake of mothers and may contribute to higher weight of offspring [ 15 ].

There is a growing body of evidence suggesting that maternal nutrition and lifestyle affect fetal growth and development [ 16 , 17 ]. Micronutrients are vitamins and minerals that enable the body to produce enzymes, hormones and other substances essential for normal growth and development [ 18 ]. Micronutrient deficiencies contribute to poor growth, intellectual impairments and increased risk of morbidity and mortality [ 19 ]. Widespread global micronutrient deficiencies exist, with pregnant women and young children at highest risk [ 19 ]. Micronutrient interventions such as supplementation of folate to prevent neural tube defects zinc to reduce risk of preterm birth, and iron to reduce the risk of low birthweight are established [ 20 , 21 , 22 ]. The micronutritional deficiencies seen after bariatric surgery might be explained by poor dietary pattern in combination with gastrointestinal modification and reduced intestinal transit time [ 23 , 24 , 25 , 26 , 27 ]. Deficiencies of fatty soluble vitamins seem to be particularly prevalent in post-bariatric pregnancies, with potential risks of impaired vision, neuronal disorders, impairment of the immune system and hypocoagulability for mother and child [ 24 , 28 , 29 , 30 ].

While sleeve gastrectomy is the most common surgical procedure for the treatment of obesity worldwide, there is conflicting evidence on the optimal surgical procedure before subsequent pregnancy [ 10 , 31 ]. A large registry study showed no difference between gastric bypass and sleeve gastrectomy for preterm birth or small for gestational age [ 12 ]. Studies indicates increased risk of prematurity in pregnancy occurring less than 2 years after bariatric surgery [ 12 , 32 ]. However, other studies have not confirmed increased risks in pregnancies related to time-interval between bariatric surgery and conception [ 13 , 33 ]. As such, there is an evident knowledge gap on the impact of bariatric surgery on micronutrient status in pregnancies as well as outcomes for mother and child in order to provide optimal obstetric care in this group.

The aim of this study was to assess the impact of bariatric surgery on concentrations of micronutrients in post-bariatric pregnancies compared with non-surgical controls. Specifically, we hypothesized that fatty soluble micronutrients, including vitamin K1, was impaired after bariatric surgery. We also wanted to assess differences in maternal micronutrients concentrations following sleeve gastrectomy versus gastric bariatric surgery.

Materials and methods

Design and study population.

This observational case control study compared micronutritional status in pregnancy after bariatric surgery with non-surgical controls. Study participants were recruited from Akershus university hospital, between October 18th 2018 and December 9th 2022. Pregnant women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A total of 59 women with a previous bariatric surgery was included in the study and information on surgical procedure was available for 57 women (gastric bypass surgery n  = 26 and sleeve gastrectomy n  = 31). All women with post-bariatric pregnancies were closely monitored individually by a clinical doctor and a registered clinical dietitian focusing on micronutrient status and gestational weight gain. The controls received standard hospital care and dietary advice with additional advice if the blood samples revealed deficiencies.

A total of 204 women were included in this study with 92% of Caucasian ethnicity ( n  = 185). We compared micronutrient status in pregnancy in women with previous bariatric surgery ( n  = 59) to controls ( n  = 145). Women with known intestinal conditions (i.e. known inflammatory bowel disease, uncontrolled coeliac disease) were not included in the study. The study was approved by the Regional Committee for Medical and Health Research Ethics (reference 25829). All study participants provided written informed consent before study commencement, and the study was performed in accordance with the Declaration of Helsinki [ 34 ].

Definitions

The reference intervals for micronutrients in non-pregnant women and the chosen cut-offs defining micronutrient deficiencies in pregnancy are presented in Table  1 . We defined micronutrient deficiency according to known physiological changes in blood during pregnancy combined with established reference intervals in a non-pregnant population [ 30 , 35 , 36 , 37 ]. Time interval between bariatric surgery and conception was categorized into < 18 and ≥ 18 months.

Data collection

Clinical and laboratory data were retrieved at mean gestational week 20.4 (SD 4.5) (Bariatric surgery 23.9 [6.5] vs. controls 19.0 [2.0] weeks, p  < 0.001). Follow-up blood sample was available in a subgroup of 32 women with post-bariatric pregnancies at mean 30.4 (SD 5.6) gestational week. All patients completed a questionnaire on comorbidities, medications and dietary supplements. Additional information including maximum weight, time of bariatric surgery, type of bariatric surgery was retrieved during the first visit.

Blood samples and analysis

The blood samples were obtained by venipuncture and collected in Vacuette® tubes. EDTA tubes were used for analysis of hemoglobin, hemoglobin A1c and thiamine (vitamin B1). Lithium heparin gel tubes were used for analysis of zinc and selenium, and serum gel tubes for the remaining analyses. All the blood samples were non-fasting. After blood collection, all tubes were handled according to established procedures. The standard clinical chemistry parameters were analysed at the laboratory at Akershus University Hospital. Hemoglobin was analysed on Sysmex instruments (Sysmex Corporation, Kobe, Japan) and hemoglobin A1c on Tosoh instruments (Tosoh Corporation, Tokyo, Japan). Magnesium and homocysteine were analysed on Vitros 5.1 FS (Ortho Clinical Diagnostics, Raritan, NJ) until May 2021, thereafter on cobas c503 (Roche Diagnostics, Mannheim, Germany). Folate, cobalamin, ferritin and vitamin D were analysed on cobas e801 (Roche Diagnostics). Zinc and selenium were analysed using inductive coupled plasma – mass spectrometry (ICP-MS) and methylmalonic acid (MMA) with a liquid chromatography – mass spectrometry method (LC-MS/MS). Thiamine, pyridoxal 5-phosphate (vitamin B6), vitamin A and vitamin E were analysed at Oslo University Hospital, Aker and vitamin K1 was analysed at Fürst Medical Laboratorium, Oslo, all with chromatographic methods.

Statistical analysis

We estimated that the prevalence of micronutrient deficiency would be 30% in post-bariatric pregnancies and 5% in controls. To confirm a similar difference with a statistical power of more than 80% and a significance level (α) of 0.05, a total of 200 patients had to be included in the study with a 4:1 ratio of cases vs. controls (40 post-bariatric pregnancies and 160 controls). Proportions are reported as numbers with percent, continuous variables as mean ± standard deviation (SD) as appropriate. Differences between treatment groups were analysed using Pearson’s chi-square test or Fishers exact test for categorical data and Student’s t-test for continuous data. Paired sample t-test was used to assess paired observations of micronutrients in baseline and follow-up blood samples. Skewed distributed data were log-transformed to achieve normal distribution. Correlations between possible confounders and vitamin K1 variables were assessed by Spearman’s correlation (rho). Two-sided P values < 0.05 were considered statistically significant. The Bonferroni Holm correction was applied to mitigate the risk of type 1 statistical error. We used linear regression analyses to explore possible associations between bariatric surgery and vitamin K1 and logistic regression analyses to explore possible associations between bariatric surgery and vitamin K1 deficiency. Possible confounders were identified using a stepwise selection approach in which variables with p-values below 0.10 were included along with clinically significant confounders. Coefficients and odds ratio (OR) from regression analysis are presented with 95% confidence interval (CI). The analyses were performed using IBM SPSS Statistics (version 729.0.0).

We included 204 women in the study (bariatric surgery n  = 59 and controls n  = 145). Data on the specific type of surgical procedure were available for 57 women who had undergone bariatric surgery prior to conception (gastric bypass surgery n  = 26 and sleeve gastrectomy = 31). The women in the surgical group lost on average 39.0 (16.9) kg from the time of surgery to the start of pregnancy and the time interval from bariatric surgery to pregnancy was mean 63.7 (39.2) months. Patients’ characteristics by surgical status are presented in Table  2 .

The women with bariatric surgery had a higher pre-pregnant body mass index (BMI) compared with controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m 2 , p  < 0.001). There was no difference between groups regarding age (32.1 [5.7] vs. 31.2 [4.2] years, p  = 0.215), maternal weight gain (13.3 [9.6] vs. 14.8 [6.5] kg, p  = 0.228), HbA1c (30.2 [7.1] vs. 31.1[3.6] mmol/mol, p  = 0.234) or development of gestational diabetes (5% vs. 5%, p  = 1.000). Fewer women with bariatric surgery had completed higher education and more women with bariatric surgery currently smoked compared with controls (24 [43%] vs. 103 [72%], p  < 0.001 and 5 [9%] vs. 0, p  = 0.001, respectively. Children of post-bariatric pregnancies had lower gestational age and lower birthweight, however neither reached statistical significance (38.5[3.1] vs. 39.3[2.1] weeks, p  = 0.054 and 3363 [624] vs. 3520 [521] g, p  = 0.081, respectively).

Dietary supplements and micronutrient status by surgical status are presented in Table  3 . Concentrations of ferritin, magnesium, pyridoxal 5-phosphate, vitamin A, E and K1 and selenium were significantly lower post-bariatric pregnancies compared with controls. Using micronutrients as categorical variables (deficiency yes/no) conferred a higher prevalence of micronutrient deficiencies such as iron, magnesium, pyridoxal 5-phosphate, vitamin K1 and selenium in pregnancies after bariatric surgery compared with controls and a higher prevalence of vitamin K1 deficiency after gastric bariatric surgery vs. sleeve gastrectomy (Fig.  1 ). The distribution of vitamin K1 concentrations in women with post-bariatric pregnancies and controls is presented in Fig.  2 . Paired sample t-test showed increased concentrations vitamin K1 in a subgroup of women with post-bariatric pregnancies (0.29 [0.29] ng/mL to 0.64 [0.92] ng/mL, p  = 0.070).

Micronutritional deficiency in pregnancy. A : pregnancy following bariatric surgery vs. non-surgical controls. B : pregnancy after gastric bypass surgery vs. sleeve gastrectomy. * denotes statistically significance after corrections for multiple comparisons

Distribution of vitamin K1 concentrations in women with post-bariatric pregnancies and controls

The women with gastric bariatric surgery underwent surgery at a younger age and with a longer time-interval between surgery and conception compared with the women with sleeve gastrectomy (23.5 vs. 27.5 years, p  = 0.002 and 85 [40] vs. 45 [28] months, p = < 0.001, respectively). One woman (4%) after gastric bariatric surgery and five women (16%) after sleeve gastrectomy, p  = 0.205 became pregnant < 18 months after surgery. Both surgical groups had lost comparable weight since surgery (gastric bypass surgery 41.4 [17.1] vs. sleeve gastrectomy 37.0 [16.8] kg, p  = 0.342) and they had comparable pre-pregnant BMI (gastric bypass surgery 31.9 [5.5] vs. sleeve gastrectomy 29.9 [6.4] kg/m 2 , p  = 0.222). The proportion of women with vitamin K1 deficiency was higher after gastric bariatric surgery compared with sleeve gastrectomy (gastric bypass surgery 9 [38%] vs. 1 [3%], p  = 0.003 and Fig.  1 ).

Univariate linear regression analysis showed that bariatric surgery was inversely associated with vitamin K1 levels (B -0.33 [95% CI -0.51, -0.15, p  < 0.001]. The result remained statistically significant after multivariable adjustments (-0.26 ng/mL [-0.51, -0.04], p  = 0.047) (Table  4 A). In addition, compared with sleeve gastrectomy, gastric bariatric surgery was inversely associated with vitamin K1 in univariate linear regression analysis (0.20 [0.019, 0.387], p  = 0.031), but not after multivariate adjustment (Table  4 B). Using vitamin K1 as a categorical variable (deficiency yes/no), bariatric surgery was associated with a fivefold increased risk of vitamin K1 deficiency compared with controls and that gastric bariatric surgery was associated with higher adjusted risk of vitamin K1 deficiency compared with sleeve gastrectomy (Table  5 ).

In this study, we compare micronutrient concentrations in post-bariatric pregnancy with matched non-surgical controls. The study shows that the concentrations of vitamin K1, magnesium, and selenium were significantly impaired in post-bariatric pregnancies vs. controls. Moreover, our results show that bariatric surgery was consistently associated with vitamin K1 levels, both as a continuous outcome variable and as a categorical variable (vitamin K1 deficiency) in post-bariatric pregnancy compared with controls. Moreover, the associations might be driven by gastric bariatric surgery rather than sleeve gastrectomy. However, the number of pregnant women with vitamin K1 concentration below the lower reference limit was overall small and the confidence intervals were large. Thus, these results should be interpreted with caution.

Maternal nutrition and micronutrients in pregnancy after bariatric surgery

In pregnancy, there is an increased need for nutrients to support fetal and placental growth and development [ 20 ]. A detailed dietary information was not available in this study and we cannot exclude that the women with bariatric surgery had a different nutritional composition compared with controls. In a subgroup of women with post-bariatric pregnancies, an increment in vitamin K was seen. However, the changes did not reach statistical significance. Follow-up blood samples for the controls were not available. A healthy diet after bariatric surgery may differ from the general population in the composition of lean protein, fruits and vegetables and starchy carbohydrates. Nonetheless, the combination of diet, intestinal modifications and increased metabolism in pregnancy might explain the deficiencies in fatty soluble vitamins seen in this study [ 23 , 24 , 25 , 26 , 27 ]. Improved nutrient intake of mothers was seen after personalized nutritional counseling during post-bariatric pregnancy and might contribute to higher birth weight of offspring [ 15 ]. Given the complexity and heterogeneity of nutritional status in post-bariatric pregnancies, focusing on sub-groups including pre-gestational nutritional deficiencies, and type of surgery performed is of vital importance. A recent consensus report recommended specialized care in pregnancies after bariatric surgery [ 38 ]. There is however a paucity of data to support clinical practice [ 38 , 39 ]. As such, there is an imperative need to identify pregnancy and trimester specific reference intervals and clinical decision limits in order to help clinical advice on dietary supplement.

Lifelong dietary supplement is recommended after bariatric surgery, however adherence to adequate dietary supplements seems to decrease over time [ 26 , 40 , 41 ]. Our study also confers inadequate use of dietary supplements in pregnancy after bariatric surgery with 30–70% of the women not taking recommended post-bariatric surgery dietary supplements (Table  3 ). Thus, a need for increased awareness to ensure adequate microntutrional care before, during and after pregnancy is imperative.

The role of vitamin K1 in pregnancy after bariatric surgery

In line with our results, a systematic review on vitamin K1 concentrations in patients with a history of bariatric surgery reported high risk of vitamin K1 deficiency after bariatric surgery and opted for better monitoring [ 23 ]. Our results also cohere with another study of 49 pregnant women with previous bariatric surgery, showing that vitamin K1 concentrations were lower in women with a history of bariatric surgery compared with 27 controls [ 30 ]. The increased fat storage in pregnancy may lead to less bioavailability for activation of fatty soluble vitamins [ 42 ]. Furthermore, the highly fat-soluble vitamin K1 depend upon conjugated bile salts for adequate absorption. Consequently, reduced stomach acid production, reduced absorption surface and shorter interaction time between conjugated bile salts and vitamin K1 might explain the lower serum concentrations of vitamin K1 after bariatric surgery [ 43 ]. Screening for vitamin K1 deficiency is usually recommended after malabsorptive surgical procedures including biliopancreatic diversion with or without duodenal switch [ 43 ]. However, restrictive procedures may also cause vitamin deficiencies due to digestive symptoms such as vomiting and food intolerance. Interestingly, lower levels of vitamin K1 were found in the first trimester compared to a control group of women without bariatric surgery [ 30 ]. Vomiting and food intolerance may also be the main symptoms of hyperemesis gravidarum, which calls for increased vigilance of vitamin K1 insufficiency in post-bariatric pregnancies in women with symptoms of hyperemesis in pregnancy.

The impact of vitamin K1 deficiency in post-bariatric pregnancies is not clear. Low circulating levels of vitamin K1 might lead to a hypocoaguble state in mother and child [ 30 ]. Some cases of neonatal intracranial bleeding have been reported, possible due to vitamin K1 deficiency [ 44 ]. Another study reported that obesity had stronger impact on hypercoagulability than pregnancy itself [ 45 ]. Nonetheless, insufficient data exist in order to recommend interventions of vitamin K1 deficiency in post-bariatric pregnancy [ 38 ]. While optimal monitoring of vitamin K1 during pregnancy following bariatric surgery remains unclear, a major concern is raised about the consistent finding of vitamin K1 deficiency in post-bariatric pregnancy.

Bariatric surgery before pregnancy: timing and selection of procedure – dose it matter?

Few studies have assessed the impact of different surgical procedures before pregnancy. One study of 119 pregnant women found no effect of maternal weight gain on maternal and perinatal outcome after sleeve gastrectomy [ 46 ]. However, the study did not include pregnancies after gastric bariatric surgery for comparison. Another retrospective observational study showed no differences between gastric bariatric surgery and sleeve gastrectomy regarding re-interventions or obstetric outcomes [ 4 ]. Conflicting evidence exists on the possible adverse effects of sleeve gastrectomy such as dyspepsia and weight regain as compared with gastric bariatric surgery [ 47 , 48 , 49 ]. Our study adds important knowledge about the different surgical procedures, suggesting that gastric bariatric surgery holds greater risk of vitamin K1 deficiency compared with sleeve gastrectomy. The optimal surgical procedure for obesity treatment in women of reproductive age is however not clear and a person-centered approach should be advocated in future guidelines.

The timing of pregnancy after bariatric surgery is moreover under debate. Current recommendations suggest waiting at least 12 months after bariatric surgery before planning a pregnancy [ 12 , 38 , 50 ]. In our study, women with previous sleeve gastrectomy had a shorter time interval between surgery and conception than the women with gastric bariatric surgery. This might reflect that the women who underwent gastric bariatric surgery underwent surgery in an era where gastric bariatric surgery was the most common surgical procedure for weight loss [ 31 ]. Interestingly, after adjustments for the time interval since bariatric surgery, gastric bariatric surgery was not associated with vitamin K1 in the linear regression model (Table  4 B). Thus, as adherence to dietary supplements is reduced with time after bariatric surgery, we cannot rule out that patient’ adherence to dietary supplement might have influenced the differences between surgical procedure seen in the present study [ 26 , 40 , 41 ]. On the other hand, the time interval between sleeve gastrectomy and conception did not impact maternal and neonatal outcomes in a study of 15 women conceived > 18 months after surgery. The authors concluded that pregnancy after sleeve gastrectomy was overall safe and well-tolerated [ 33 ]. Furthermore, a study of 30 women who became pregnant within a mean time of 17 months after gastric bariatric surgery did not appear to confer any serious risks in pregnancy with 90% of the children were born at term with normal birthweight [ 13 ]. In our study, only six patients (11%) became pregnant earlier than 18 months after surgery and the study was not designed to assess pregnancy or birth related complications.

Future implications?

The results of this study underscore the need for increased awareness of nutritional and microntutrional status to ensure adequate obstetric care both before and during post-bariatric pregnancies. Also, this study present important information on adherence to dietary supplement that should be considered in the planning of post-bariatric pregnancies. Moreover, the results of our study rises important questions on the impact of micronutrients deficiencies on future child development.

Strengths and limitations

The strengths of this study include the prospective design with matched controls. Moreover, definitions for the chosen cut-offs for micronutrient deficiency were chosen according to pregnancy specific reference intervals if established. However, we cannot rule out that the concentrations of the micronutrients change in pregnancy. Thus, the validity of the chosen cut-offs for defining micronutrient deficiency should be assessed in future studies. This study was a small single center study and did not have the statistical power to assess pregnancy related or birth related complications. The majority of the women in this study was Caucasian and the results may not be valid in populations of other ethnicities. The observational design does not provide any causality between variables. Also, we cannot rule out if the difference in gestational week for blood sampling or non-fasting blood samples might have influenced the micronutrient analyses. Finally, use of dietary supplements was self-reported and we cannot be sure that all the study participants adhered with the recommendation.

This study shows that concentrations of the micronutrients vitamin K1, magnesium, and selenium were significantly impaired in post-bariatric pregnancies compared with controls. We found a negative association between bariatric surgery and vitamin K1 and a higher risk of vitamin K1 deficiency after gastric bariatric surgery compared with sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be assessed in future studies.

Data availability

The data used in the present study is not open access or publicly available. The datasets are available from the corresponding author on reasonable request.

Abbreviations

Body mass index

Confidence interval

Standard deviation

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Acknowledgements

We acknowledge the work of the staff at the Section for Morbid Obesity at Akershus University Hospital HF for the persistent effort of data collection.

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Brit Torunn Bechensteen, Jacob A. Winther & Tone G. Valderhaug

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Contributions

TGV and EMRS designed the study. BTB, EMRS and TGV collected the data for the study. TGV analysed the data. BTB and TGV drafted the manuscript. CS ad GK were responsible for the laboratory analyses. TGV and JAW were responsible for the statistical analyses. All authors contributed to the interpretation of data, reviewed and edited the manuscript and gave their final approval of the final version to be published.

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Correspondence to Tone G. Valderhaug .

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Goats and Soda

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Glasses aren't just good for your eyes. They can be a boon to income, too

Gabrielle Emanuel

Reading glasses are easy to come by in Western countries. But getting a pair in the Global South can be a challenge. A new study shows the surprising benefits that a pair of specs can bring. Maica/Getty Images hide caption

Reading glasses are easy to come by in Western countries. But getting a pair in the Global South can be a challenge. A new study shows the surprising benefits that a pair of specs can bring.

Jasmin Atker calls her reading glasses her best friend – and a companion she does not take for granted. But her spectacles do something most best friends don't do: They help her make a lot more money.

Atker, 42, is a grandmother who lives in Manikganj, Bangladesh, on a small family farm. It started as a cattle farm producing milk. After she got glasses through the nonprofit groups VisionSpring and BRAC in 2022, Atker says, her improved vision enabled her to set up a vegetable patch. She even learned how to grow mushrooms. She now sells mushrooms as well as pumpkins, watermelon and spinach at the market. Atker estimates that her monthly income has jumped from 9,000 to 10,000 Bangladeshi taka to closer to 15,000 to 17,000 taka – the equivalent of about $150.

"Before, when I tried to cut vegetables and wanted to see if there were any insects or not, I couldn't see properly," Atker says, speaking through an interpreter. "After [I got] the glasses, the average time that I take for each task has reduced significantly. And I can do more work ... [and] I have this sense of independence."

There's now data that suggests Atker's story is common. For the first time, researchers have directly linked glasses and income.

The study – published Wednesday in PLOS ONE – found a dramatic increase in earnings with a very low-cost change: a new pair of reading glasses.

The researchers went to 56 villages in Bangladesh and found more than 800 adults ages 35 to 65 who are farsighted – that is, they could not see well up close. Half were randomly selected to get glasses; the other half got glasses after eight months. In that time, the researchers found that income grew by 33% for those with glasses – from a median monthly income of $35 to $47 – and that people who were not in the workforce were able to start jobs after getting reading glasses.

"This is a really big study," says Dr. David Friedman , a professor of ophthalmology at Harvard Medical School, who was not involved in the project. "This is the first time we can really say that something that will improve [someone's] quality of life from a visual standpoint will also help with poverty alleviation, which is an enormous finding."

In the U.S., the U.K. and many other European countries, reading glasses are readily available over-the-counter at most drugstores. That's not the case elsewhere.

A pair of glasses can be hard to find

"In a lot of low- and middle-income countries, glasses are still tightly regulated," says Dr. Nathan Congdon , a co-author of the study and chair of Global Eye Health at Queen's University Belfast. People often have to get a prescription from a vision specialist before they can purchase glasses, even reading glasses. This proves to be a huge hurdle for those living in poverty and those in remote areas, he says.

The study did more than quantify the income gains from glasses. The researchers also taught community health workers in just a few hours how to help people pick the right reading glasses.

The focus of this study was on reading glasses for near vision. That's because fitting someone with distance glasses is like tailoring a custom-made suit, with careful measurements and adjustments. Reading glasses are akin to buying off the rack, with just a few strengths to choose between.

"It's a little bit like buying a pair of trousers where you've got small, medium, large, extra large – four or five, six different sizes," says Congdon. This makes reading glasses easier and cheaper to produce.

"The glasses themselves cost maybe $3-4. And using village health workers, we can make the cost of delivery very inexpensive as well," said Congdon. "So the whole thing can really just be a handful of dollars to deliver something that's potentially quite life changing."

This study's findings fit with past studies that link glasses to productivity. For example, Congdon was involved in a study, in India, where tea pickers given glasses were more productive. Similarly, cataract surgery has been shown to increase economically valuable activities by 40% to 50%.

The villagers in the study worked in a wide range of professions: shopkeepers, farmers, craftspeople and weavers, for example. Only about a third of them were literate. So the reading glasses weren't for reading as much as for other daily tasks, like threading a needle, quickly figuring out change at a cash register or weeding and sorting grain on a family farm.

What the participants had in common is they had presbyopia – as do over a billion people today. This condition happens naturally as people age. A youthful eyeball can shift its focus from something far away to something up close by adjusting the shape of its lens. But, around the age of 40, the eye gradually loses this ability – and the ability to see up close. Glasses can fix this.

Congdon would like to see regulations loosen to improve access to reading glasses. He says the regulations, the cost and a general lack of awareness have meant many people who need glasses go without. When searching for participants, his team met almost nobody in the Bangladeshi villages with glasses.

The state of global vision care: in need of correction

Congdon, who is an ophthalmologist himself, largely blames his own profession.

"Ophthalmologists and optometrists may be advising the government that they should tightly regulate access to these products [to] strengthen their professions. They may see themselves as gatekeepers of quality," he says. "I wouldn't be recommending that we just hand out distance glasses, but I do think that for near [vision] glasses that's a reasonable thing to do."

He says some for-profit companies and countries have successfully experimented with providing people with glasses. "Dozens of companies in coffee, tea, chocolate, textiles and other visually intensive sectors – they started to offer these programs, all across India and in many African countries," Congdon says.

Friedman, of Harvard Medical School, says he'd like to see Congdon's study replicated in other environments and is hopeful such evidence could persuade global health professionals to pay more attention to vision care.

"Fatal diseases, childhood mortality or things that kill adults are really emphasized in the health-care system. And we see less money put into eye care," he says. "But eye care enables people to work and maintain their lives, which is hugely important."

For Atker of Bangladesh, she says she barely goes anywhere without her "best friend" glasses. From writing down how much milk she got from her cows to checking her phone, she says her livelihood depends on them.

"Without glasses, I can't do anything," she says.

• Reading glasses

• Case report
• Open access
• Published: 04 April 2024

Expression analysis of zinc-metabolizing enzymes in the saliva as a new method of evaluating zinc content in the body: two case reports and a review of the literature

• Ken-ichiro Sakata 1 ,
• Ayako Hashimoto 2 ,
• Taiho Kambe 3 ,
• Jun Sato 1 ,
• Noritaka Ohga 1 ,
• Yutaka Yamazaki 4 ,
• Masahide Koyachi 5 ,
• Itagaki Tatsuki 1 ,
• Mai Okada 1 ,
• Okura Taro 1 ,
• Hiroshi Hikasa 1 &
• Yoshimasa Kitagawa 1  

Journal of Medical Case Reports volume  18 , Article number:  198 ( 2024 ) Cite this article

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The activity level of alkaline phosphatase, a zinc-requiring enzyme in the serum, is used to indicate zinc nutritional status; however, it does not correlate with serum zinc levels or subjective symptoms of taste disorder in many cases. Hence, this study focused on the total activity of alkaline phosphatase, a zinc-requiring enzyme. The total alkaline phosphatasa activity level in the saliva was measured before and after zinc supplementation, and the results were compared with serum zinc levels.

Case presentation

This study included patients with hypozincemia, specifically a patient with zinc-deficient taste disorder (patient 1: a 69-year-old Japanese woman) and a patient with glossodynia with zinc deficiency (patient 2: an 82-year-old Japanese woman). Saliva samples were collected, and blood tests were performed before and after zinc supplementation. Subjective symptoms and serum zinc levels were simultaneously evaluated. Zinc supplementation was performed using zinc acetate hydrate or Polaprezinc.

Conclusions

Total alkaline phosphatase activity levels were found to be associated with serum zinc levels and subjective symptoms. A further study with a higher number of patients is necessary to confirm whether total alkaline phosphatase activity levels more accurately reflect the amounts of zinc in the body than serum zinc levels.

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Zinc deficiency in humans was recognized for the first time in 1961 [ 1 ]. Studies have reported that zinc deficiency is associated with taste disorder and glossodynia [ 2 , 3 , 4 ]. There are several other symptoms, such as bedsores, skin symptoms, delayed wound healing, fetal growth restriction, chronic diarrhea, anemia, and altered mental status [ 5 ]. The Zincage Project (research on the relationship between health/aging and zinc), an epidemiological survey in Europe, has shown that health status of older adults is positively associated with the amount of zinc in the body [ 6 ]. In the basic research field, zinc is considered an essential trace metal element, with approximately 2 g being present in the body. Zinc plays a role as the active center of 3000 types of enzymes and bioactive substances [ 7 ]. Recent human genome decoding projects have indicated that approximately 10% of genes have zinc-binding domains. Hence, researchers have focused their attention on the relationship between zinc and diverse physiological functions, including zinc transporters and zinc signals [ 8 ]. Sequelae of oral diseases caused by zinc deficiency lead to a frailty cycle. This cycle stems from appetite loss and decreased food consumption, causing undernutrition. This state results in weight loss and sarcopenia onset (Fig.  1 ).

Hypozincemia leads to frailty

To address this issue, accurate measurement of the zinc content in the body is required in clinical practice, highlighting the need to develop a method for accurate and rapid diagnosis of zinc deficiency. Zinc deficiency is known as the main factor contributing to taste disorder [ 9 ]. However, it is not well known that zinc deficiency can also cause several oral diseases, such as mouth ulcers and glossodynia, posing a diagnostic and treatment challenge in many cases [ 10 ]. Serum zinc levels are a commonly used indicator of zinc assessment in clinical practice. However, they do not accurately reflect the zinc content in the body, because they account for only less than 0.1% of the total zinc in the body [ 3 ]. Furthermore, they exhibit circadian rhythms and are easily influenced by several conditions. Owing to such disadvantages, they are not considered an absolute indicator [ 11 ]. In this study, we attempted to identify an indicator other than serum zinc levels for accurately measuring the amount of zinc in the body, focusing our attention on zinc-requiring enzymes, which show zinc-dependent activity. Zinc-requiring enzymes are activated after binding to zinc. The activity level of alkaline phosphatase (ALP), a zinc-requiring enzyme in the serum, is used as an indicator of zinc nutritional status; however, it does not correlate with serum zinc levels or subjective symptoms of taste disorder in many cases. To accurately evaluate the zinc nutritional status, we shifted our focus from serum ALP to total alkaline phosphatase [ 12 , 13 ]. Four ALP isozymes are  broadly expressed in various cells (Table  1 ). Previous studies using cultured cells and animals have shown that ALP, an enzyme that is activated by coordinating zinc at the active center, plays a role in suppressing inflammation by hydrolyzing adenosine triphosphate (ATP), which serves as a danger signal extracellularly, into adenosine. The results demonstrate that ALP is a zinc-requiring enzyme (zinc marker enzyme), enabling the accurate measurement of zinc content in the body [ 14 ].

Objective: Intervention is required to break the frailty cycle; however, the following questions remain unsolved: “Which indicators should be used for zinc supplementation?”, “How long should zinc supplementation be continued?”, and “How much zinc is required for the supplementation?” We raised the possibility of conducting translational research in which basic scientific findings are translated into clinical practice, with the aim of attaining a society where “older adults can enjoy meals.” This study aimed to evaluate total ALP activity levels in the saliva, serum zinc levels, and subjective symptoms before and after zinc supplementation in patients with oral diseases caused by zinc deficiency.

Patients and methods

Saliva samples were used because they can be collected repeatedly in a noninvasive manner. They were collected before and after zinc supplementation, and subjective symptoms of taste disorder and serum zinc levels were simultaneously evaluated. Saliva sample collection and blood tests were performed only in the morning. The gustatory testing (whole mouth) results are as follows: Four types of taste solutions [sucrose (S), sodium chloride (NaCl; N), tartaric acid (T), and quinine hydrochloride dihydrate (Q)] were dropped on the dorsum of the tongue at the following concentrations (No. 1: 2.9 μmol, No. 1.5: 5.8 μmol, No. 2: 8.8 μmol, No. 2.5: 17.5 μmol, No. 3: 29.2 μmol, No. 4: 58.4 μmol, and No. 5: 2337 μmol), and cognitive thresholds were tested by tasting the samples within 2–3 seconds. Taste perception threshold testing followed the criteria in the table below, and when No. 5 could not be recognized, it was considered taste loss. The efficacy of zinc supplementation in patients with taste disorder and those with burning mouth syndrome (BMS) was evaluated using the Visual Analog Scale [ 15 ] and Numerical Rating Scale [ 16 ], respectively. Zinc content was measured using ACCURAS AUTO Zn (Shino-Test Corporation, Osaka, Japan).

Zinc was measured using the Acurus Auto Zn (Shino-Test Corporation, Tokyo, Japan) based on the colorimetric method using an automated analyzer (Hitachi 7700 series; Hitachi High-technology Corporation, Tokyo, Japan). Measurement of ALP activity in saliva was performed as follows: 5 µl of saliva was used to measure ALP activity. A total of 100 μl of substrate solution [2 mg/ml disodium  p -nitrophenylphosphate hexahydrate ( p NPP); Wako Pure Chemicals in 1 M diethanolamine buffer pH 9.8 containing 0.5 mM MgCl 2 ] was added and incubated at 37 ℃ for 1 hour. The released  p -nitrophenol product was quantified by measuring the absorbance at 405 nm.

Calf intestinal ALP (Promega) was used to generate a standard curve. This study was approved by the Hokkaido University Hospital Independent Clinical Research Review Committee (Approval No. 019-0337) and approved by the Ethics Committee of Kyoto, University Graduate School and Faculty of Medicine (Approval No. R3275).

All study procedures were performed in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.

Two patients experiencing hypozincemia were included. Patient 1 was a 69-year-old Japanese woman (Fig.  2 ). The patient presented to the Dentistry Center, Hokkaido University Hospital, with the chief complaint of hypogeusia. In addition to routine intraoral examination, the patient received gustatory testing, oral bacteria testing, blood tests, and chewing gum test. Intraoral examination showed mild xerostomia and tongue coating. The results of gustatory testing (whole mouth) were sweet (2.5), salty (4), sour (2), and bitter (2), indicating hypogeusia. Oral bacteria testing was unremarkable. The volume of saliva collected using the chewing gum test was 17.8 mL. Blood tests at the initial visit showed a serum zinc level of 65.6 μg/dL. Based on this low serum zinc level, the patient was diagnosed with zinc-deficient taste disorder. The total ALP activity level was 0.072 mU/5 μL. Zinc supplementation was continued for 2 months using zinc acetate hydrate. After the patient orally took zinc acetate hydrate 50 mg for 1 month, the serum zinc level improved to 115.3 μg/dL, and the total ALP activity level increased to 0.102 mU/5 μL. After the zinc acetate hydrate dose was reduced to 25 mg, the serum zinc level slightly decreased to 86 μg/dL. However, the total ALP activity level remained almost the same at 0.1 mU/5 μL.

69-year-old woman with taste disorder

Patient 2 was an 82-year-old Japanese woman (Fig.  3 ). The patient presented to the Dentistry Center, Hokkaido University Hospital, with the chief complaint of glossodynia. In addition to routine intraoral examination, she received gustatory testing, oral bacteria testing, and blood tests. Intraoral examination showed mild tongue coating. The results of gustatory testing (whole mouth) were sweet (1.5), salty (2.5), sour (2.5), and bitter (2), indicating hypogeusia. Results of oral bacteria testing were positive for Candida albicans . Administration of amphotericin B gargles eradicated C. albicans . However, glossodynia persisted after the eradication; therefore, the patient was diagnosed with BMS secondary to zinc deficiency. Blood tests at the initial visit showed a serum zinc level of 51.9 μg/dL. On the basis of this low serum zinc level, the patient was diagnosed with BMS secondary to zinc deficiency. The total ALP activity level was 0.045 mU/5 μL. Zinc supplementation was continued for 5 months using zinc acetate hydrate. After the patient orally took zinc acetate hydrate 50 mg for 1 month, the serum zinc level improved to 113.3 μg/dL, and the total ALP activity level increased to 0.05 mU/5 μL. The patient received a reduced zinc acetate hydrate dose of 25 mg for the subsequent month of zinc supplementation, and the serum zinc level and total ALP activity level 2 months after treatment initiation were 126.6 μg/dL and 0.03 mU/5 μL, respectively. Zinc acetate hydrate 25 mg was administered every other day over the third and fourth months after the initiation of zinc supplementation. Serum zinc and total ALP activity levels 4 months after treatment initiation were 71.3 μg/dL and 0.049 mU/5 μL, respectively. Zinc acetate hydrate 50 mg was administered for the fifth month after the initiation of zinc supplementation. Serum zinc and total ALP activity level 5 months after treatment initiation were 116.6 μg/dL and 0.056 mU/5 μL, respectively. The serum zinc level decreased transiently, but the total ALP activity level remained almost the same.

An 82-year-old woman with glossodynia

Discussion and conclusions

Unstable serum zinc levels.

Currently, zinc supplementation is performed on patients with taste disorder and glossodynia due to zinc deficiency based on serum zinc levels. Our previous study showed that the mean serum zinc level was 72 μg/dL in the taste disorder group and 74 μg/dL in the control group, with no relationship between taste disorder and serum zinc levels [ 17 ]. The proportion of patients with zinc deficiency in the taste disorder group was significantly higher ( p  < 0.05) only when a serum zinc level of < 60 μg/dL (that is, severe zinc deficiency) was used to identify patients with zinc deficiency. Possible explanations for the absence of an association between clinical symptoms and serum zinc levels include: (1) Serum zinc levels do not accurately reflect the zinc content in the body; (2) serum zinc levels exhibit a large fluctuation of circadian rhythms and are easily influenced by meals, stress, and hormone conditions, therefore making them problematic as an indicator of zinc deficiency; and (3) differences in serum zinc levels between laboratories (serum zinc levels tend to show a higher value in outsourcing examination than in-hospital examination owing to hemolysis). These disadvantages suggest that serum zinc levels may not reflect the bioavailability of zinc in the body in some cases. Thus, selecting an appropriate sample and developing a method to analyze the sample are important issues.

Taste disorder and zinc

The relationship between taste disorder and zinc deficiency plays an important role in regenerating taste bud cells. Taste buds, or taste sensors, are actively regenerated approximately every 10 days. Normal regeneration of taste bud cells is required to correctly recognize different tastes. Insufficient regeneration of taste bud cells due to zinc deficiency is associated with a decrease in the number of these cells, causing impairment of taste sensor function. Zinc plays an important role in protein formation that is required for cell regeneration and transmission of genetic information.

Glossodynia and zinc

Glossodynia is a traditionally well-known symptom of hypozincemia in clinical practice; however, its evident cause is unknown [ 18 ]. Zinc exerts analgesic effects when administered locally to the spinal nerves or peripheral nerves or systemically in patients with chronic pain in areas other than in the oral area, renal dysfunction, anemia, and itchy sensation on the skin [ 19 , 20 ]. The mechanism of this analgesic effect was reported in a study in 2011 [ 21 ]. In the said study, increased sensitivity to pain was observed in knockout mice whose zinc ion binding to the NMDA-type glutamate receptor was inactivated. The authors reported that C fibers were particularly affected as compared with Aδ fibers, resulting in difficulty in suppressing chronic pain. Chronic glossodynia signals are transmitted to the brain mainly via C fibers, suggesting that the association between hypozincemia and glossodynia may be mediated by NMDA receptors, although the details remain to be clarified.

Total ALP activity levels

Both patients experienced a transient decrease in serum zinc levels, but total ALP activity levels did not change. Total ALP activity is involved in the dephosphorylation of various physiological substrates and has vital physiological functions, including extraskeletal functions such as neuronal development, detoxification of lipopolysaccharide, an anti-inflammatory role, bile pH regulation, and maintenance of the blood–brain barrier. Total ALP activity has also been reported to be involved in cardiovascular calcification, chronic kidney disease, and type 2 diabetes [ 22 ]. In particular, it is a logical clinical target to attenuate vascular calcification. Total ALP activity has gained attention as a clinical marker in several diseases. The relationship between total ALP activity levels and changes in zinc content in the body has been evaluated only in studies using cultured cells and animals. Thus, this is the first study to report the relationship in humans. Furthermore, this study used saliva samples; therefore, the results are extremely useful because these samples can be collected repeatedly in a noninvasive manner. Further cross-sectional or cohort studies are required to clarify the relationship between serum zinc levels and zinc-requiring enzymes, including total ALP activity, to interrupt the disease cycle due to zinc deficiency and improve the health status. This study suggests that total ALP activity may be a new diagnostic marker alternative to serum zinc levels. Furthermore, it may be used as an indicator when assessing the efficacy of zinc supplementation.

Availability of data and materials

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Abbreviations

Alkaline phosphatase

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Acknowledgements

I would like to give my heartfelt thanks to Prof. Kitagawa whose comments and suggestions were immeasurably valuable throughout the course of my study. I am also in debt to Prof. Yamazaki whose meticulous comments were enormously helpful. I would like to express my gratitude to Mr. Taiho Kambe and Ayako Hashimoto, for the valuable advice for evaluating zinc content in the body. I would also like to thank my family for their moral support and warm encouragement.

This study was partially supported by Lotte Co., Ltd., Tokyo, Japan.

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Department of Oral Diagnosis and Medicine, Division of Oral Pathobiological Science, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Sapporo, Japan

Ken-ichiro Sakata, Jun Sato, Noritaka Ohga, Itagaki Tatsuki, Mai Okada, Okura Taro, Hiroshi Hikasa & Yoshimasa Kitagawa

Department of Food and Nutrition, Faculty of Home Economics, Kyoto Women’s University, Kyoto, Japan

Ayako Hashimoto

Department of Applied Molecular Biology, Division of Integrated Life Science, Graduate School of Biostudies, Kyoto University, Kyoto, Japan

Taiho Kambe

Department of Gerodontology, Division of Oral Health Science, Faculty of Dental Medicine and Graduate School of Dental Medicine, Hokkaido University, Sapporo, Japan

Yutaka Yamazaki

Department of Oral Pathobiological Science and Surgery, Tokyo Dental College, Tokyo, Japan

Masahide Koyachi

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Contributions

Conceptualization: KS and JS. Methodology/formal analysis: AH and TK. Investigation: OT and TI. Resources: KS and NP. Data curation: KS. Writing—original draft preparation: KS. Writing—review and editing: YY. Visualization: NO, MO, and HH. Supervision: YK. Project administration: KM. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Ken-ichiro Sakata .

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In this report, we anonymized personal information and ensured the protection of privacy. This study was approved by the Hokkaido University Hospital Independent Clinical Research Review Committee (Approval No. 019–0337) and approved by the Ethics Committee of Kyoto, University Graduate School and Faculty of Medicine (Approval No. R3275). Written informed consent was obtained from all participants.

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Sakata, Ki., Hashimoto, A., Kambe, T. et al. Expression analysis of zinc-metabolizing enzymes in the saliva as a new method of evaluating zinc content in the body: two case reports and a review of the literature. J Med Case Reports 18 , 198 (2024). https://doi.org/10.1186/s13256-024-04463-w

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Received : 20 November 2023

Accepted : 16 February 2024

Published : 04 April 2024

DOI : https://doi.org/10.1186/s13256-024-04463-w

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• Zinc-metabolizing enzymes
• Total ALP activity

Journal of Medical Case Reports

ISSN: 1752-1947

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