TOPIC 6

LEGAL MANDATES RELATED TO NUTRITION AND DIET THERAPY

Introduction

The word ‘mandate’ comes from the Latin word mandatum which means an
order or an instruction. In politics, mandate is defined as the authority, granted by the
electorate to a person or to a party that wins an election, to carry out a policy and act
as its representative. A mandate has a political, but also a legal, nature. In
constitutional law, a mandate is a set of principles that govern the relationship
between the sovereign (voters) and the person who exercises the function for which
he or she has been elected.

Mandate means a statutory requirement or appropriation which requires a political

subdivision of the state to establish, expand, or modify its activities in a manner
which necessitates additional combined annual expenditures of local revenue by all
affected political sub- divisions of at least one hundred thou- sand dollars, or
additional combined expenditures of local revenue by all affected political
subdivisions within five years of enactment of five hundred thousand dollars or more,
excluding an order issued by a court of this state.

Learning Outcomes

At the end of the lesson, the students should be able to:

Understand legal mandates which are related to nutrition and diet therapy.

Learning Content

1. Food and Drug Administration (FDA)

2. Health Issuance Portability and Accountability Act
(HIPAA)
3. National Nutrition Council of the Philippines (NCCP)

Food and Drug Administration (FDA)

The Food and Drug Administration (FDA) is a government agency established

in 1906 with the passage of the Federal Food and Drugs Act. The agency is
separated into divisions that oversee a majority of the organization's obligations
involving food, drugs, cosmetics, animal food, dietary supplements, medical devices,
biological goods, and blood products.

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 The FDA is known for its work in regulating the development of new drugs.
The FDA has developed rules regarding the clinical trials that must be done on all
new medications. Pharmaceutical companies must test drugs through four phases of
clinical trials before they can be marketed to individuals.

 The FDA inspects and reviews production facilities that make products like
food, medicine, tobacco, and other items regulated by the agency.

 The FDA gives approval to regulated products before they can be sold in the
U.S.

 FDA has the power to recall products on the market, if necessary, for safety
and other reasons.

According to the FDA, the agency holds responsibility for monitoring the safe
consumption of medical products, food, and tobacco. The FDA is relevant for
investors specifically in regards to biotech and pharmaceutical companies. FDA
approval can be crucial to companies that are heavily involved in developing new
drugs. Without the agency’s approval, regulated products under the FDA's purview
cannot be released for sale in the United States.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA) is only

regulated in the United States which makes it challenging for the healthcare industry
to outsource work. Because of reduced oversight it is difficult to have overseas
companies understand and communicate the need for identifying and reporting data
breaches.
In the Philippines, the legislature has adopted the HIPAA model and passed
the Data Privacy Act (DPA), RA 10173 , in 2012. While patterned loosely after
HIPAA, there are some prominent features in the Philippines’ DPA. The DPA
“protects individuals from unauthorized processing of personal information that is (1)
private, not publicly available; and (2) identifiable, where the identity of the individual
is apparent either through direct attribution or when put together with other available
information.” From these two important qualifiers, the DPA attempts to cover the
entirety of data privacy – not just healthcare information. It limits its scope to what is
considered private information that is identifiable with the person of the individual
and protects agencies handling information from frivolous suits.
“Personal information must be collected for reasons that are specified, legitimate,
and reasonable…. [individuals] must opt in for their data to be used for specific
reasons that are transparent and legal.” This approach to information protection
actively involves the individual who owns the information and agencies cannot act
without their express approval. Any agencies that break this rule are liable for
damages and jail time.

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 Compounding on the type of protected information, the law specifies the level
of diligence required for managing it: “These agencies must be active in ensuring
that other, unauthorized parties do not have access to their customers’ information.”

National Nutrition Council

The NNC, as mandated by law, is the country's highest policy-making and

coordinating body on nutrition.

NNC Core Functions

1. Formulate national food and nutrition policies and strategies and serve as
the policy, coordinating and advisory body of food, nutrition and health
concerns;
2. Coordinate planning, monitoring, and evaluation of the national nutrition
program;
3. Coordinate the hunger mitigation and malnutrition prevention program to
achieve relevant Millennium Development Goals;
4. Strengthen competencies and capabilities of stakeholders through public
education, capacity building and skills development;
5. Coordinate the release of funds, loans, and grants from government
organizations (GOs) and nongovernment organizations (NGOs); and
6. Call on any department, bureau, office, agency and other instrumentalities
of the government for assistance in the form of personnel, facilities and
resources as the need arises.

NNC Vision Statement

 NNC is the authority in ensuring the nutritional well-being of all Filipinos,

recognized locally and globally, and led by a team of competent and
committed public servants.

NNC Mission Statement

To orchestrate efforts of government, private sector, international organizations and

other stakeholders at all levels, in addressing hunger and malnutrition of Filipinos
through:

 Policy and program formulation and coordination;

 Capacity development;
 Promotion of good nutrition;
 Nutrition surveillance;
 Resource generation and mobilization
 Advocacy; and

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  Partnership and alliance building
TOPIC 7

ETHICO-MORAL PRINCIPLES RELATED TO CULTURAL AND SPIRITUAL

PREFERENCES

Learning Outcome

At the end of the lesson, the student should be able to:

Understand the ethico-moral principles related to cultural and spiritual
preferences.

Learning Content

1. Nutritional Genomics
2. Nutritional Support and End-of-Life Decision
Making
3. Social, Political and Economic Issues and
Concerns affecting Nutrition Care

Nutritional Genomics

Nutritional genomics, also known as nutrigenomics, is a science studying the

relationship between human genome, nutrition and health. People in the field work
toward developing an understanding of how the whole body responds to a food via
systems biology, as well as single gene/single food compound relationships.

Since the completion of the human genome project in April 2003, research
projects into the effects of diet on the genome have grown exponentially. Nutrition
intake is both affected by, and affects, a person’s genes. The ability of the body to
take in nutrition, use nutrition effectively, and burn energy in an optimal way can vary
greatly between individuals. Conversely, the nutrition given to a body can affect the
way the genes are expressed, leading to phenotype changes. Studying the DNA of
an individual can therefore be used to generate a personalized dietary plan.

Genes, nutrition and risk factors

Reducing disease risk

In certain individuals, diet can be a major risk factor for a number of diseases,
such as type-2 diabetes or cardiovascular diseases. For example, methionine is an
important amino acid in various metabolic processes in the body created by the

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activity of an enzyme on folate (vitamin B9). A mutation in the gene that creates this
enzyme leads to less production of methionine, causing an increased risk of vascular
disease. A diet high in folate can help to alleviate this risk.

Genes and food preferences

The foods that we enjoy, and don't enjoy, has also been linked to our genes.
A preference for bitter or sweet foods is partially influenced by taste receptors T2Rs
and T1R which can lead to overeating sweet, sugar-rich foods, while variation in
ankyrin-B gene induces fat cells to store glucose at a much higher rate than normal.

The desire to consume food is governed by a variety of signals, such as blood sugar
levels, the presence of certain nutrients, signals from the gastrointestinal tract, and
many other sources of information. Genetic factors affecting these signals can lead
to under or overeating.

Nutrition can alter genetics

Chemicals that are commonly present in the diet can alter the expression of
some genes. Genes can be switched on or off by epigenetic processes, such as
methylation or addition of a methyl group to DNA that can suppress DNA
transcription. Methylation of DNA particularly takes place during the pre-natal period,
but also continues throughout childhood and into adult life.

Low-calorie intake or overeating of high fat and low protein foods during
pregnancy can lead to epigenetic events that make obesity more likely in infants.
This may be an evolved response to times of hardship, where a child is programmed
to store nutrition more effectively, although the exact mechanism is not yet fully
understood.

Overfeeding of neonatal mice can provoke permanent changes in DNA

methylation in the liver, while adults having a restricted diet (without malnutrition)
experience fewer methylation events and exhibit age-related changes more slowly.

Nutritional Support and End-of-Life Decision Making

Nutrition support alone does not reverse or cure a disease or injury. It is adjunctive
therapy that enables a patient to meet nutrient needs during curative or palliative
therapy. Nutrition support via a feeding tube or intravenous catheter is a lifesaving
therapy for patients who are unable to meet nutrient needs orally. Guidelines are

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available that provide timelines for how long clinicians should allow inadequate
intake before initiating nutrition support.1 However, the timeline for starting and
stopping nutrition support in terminally ill patients is often less clear to the clinician,
resulting in angst over what is “the right thing to do.”

Burdens of Nutrition Support

There are considerable data indicating that it is not beneficial to provide nutrition
support for patients with an irreversible (permanent vegetative state or advanced
dementia) or terminal (death anticipated within six months) illness. Seventy
prospective randomized controlled trials of nutrition support in cancer patients were
reviewed and showed no clinical benefit to this patient population. Evidence
suggests that providing nutrition support can contribute to increased suffering in
terminally ill patients due to increased nausea, vomiting, bleeding, edema,
pulmonary edema, incontinence (bladder and bowel), or infections, as well as a
potential requirement for patient restraint.

The notion that withholding nutrition support contributes to pain and suffering has
also been debated. Positron emission tomography scans have demonstrated that
when a patient is in a persistent vegetative state, the brain areas responsible for pain
perception do not function. Therefore, providing nutrition support to this patient
population to provide comfort and reduce suffering is not science based. Some
studies of patients who are dying have indicated that thirst and hunger are not a
significant problem when patients decide to forgo nutrition support and hydration. A
study of nurses caring for terminally ill patients who voluntarily chose to stop food
and fluid intake reported the nurses’ median score of the quality of the patients’
deaths as 8 (range: 0 equaled very bad death and 9 equaled very good death). For
patients with irreversible or terminal illness, it appears that nutrition support may not
benefit the patient but may increase suffering and hasten death.

Benefits of Nutrition Support

Nutrition support has been shown to benefit competent patients by reducing physical
deterioration, improving quality of life, and preventing the emotional effect of
“starving the patient to death.” Practice guidelines for palliative care in adults with
progressive head and neck cancer reported that tube feeding improved nutrient
intake, quality of life, and fluid status.10

Home nutrition support can be a lifetime commitment for patients with intestinal
failure due to either surgical removal or disease/treatment-related impairment of a
portion of the gastrointestinal tract. Nutrition support is life sustaining, but does it
have a positive impact on a patient’s quality of life? Bozetti and colleagues examined
the quality of life for patients with advanced cancer on home parenteral nutrition
(HPN).11 The patients were severely malnourished, had limited swallowing ability,
and were no longer receiving curative therapy. The researchers reported that quality
of life was better for patients who received HPN for a minimum of three months.

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Therefore, the anticipated life expectancy for patients with advanced cancer may be
a factor to consider when examining potential benefit vs. burden.

Palliative vs. Hospice Care

Palliative care provides physical symptom management, emotional support, and
spiritual comfort when no curative therapy is available or after making the decision to
no longer continue curative or life-prolonging therapies. The transition from curative
to palliative therapy should be a continuum of care to diminish any feeling of
abandonment by the patient and family.

Hospice care integrates palliative care into “focus on relieving the substantial
symptom burden patients face at the end of life, as well as advanced care planning
needs, existential concerns, and family and social stressors.”20 A study by Lorenz et
al revealed that 63% of 149 hospices surveyed in California reported denying
admission to patients receiving complex therapy, including PN (38%), EN (3%),
chemotherapy (48%), and radiation (36%). Freestanding hospice programs were
more likely to deny admission based on these criteria than hospice programs that
were part of a statewide or national chain. These restrictive admission criteria could
inhibit patients from entering a hospice program. Hospice care should ideally begin
approximately six months prior to death. The imprecise ability to predict death and
the fear that accepting hospice care is “giving up” results in many patients entering it
weeks, days, or hours before their death.

Debate Over Hydration

Hydration’s role in the dying process has been debated. Fear of making patients
uncomfortable due to thirst encourages clinicians and families to provide fluids to
patients when oral intake is declining or artificial nutrition has been discontinued.
Small studies have suggested that fluids play a minimal role in patient comfort as
long as meticulous mouth care is provided.6,7 Based on his 20 years of experience
working with terminally ill patients, Fine observed that providing “comfort foods” and
oral hydration was therapeutic for the patients. The oral intake of fluids decreases
during the dying process. Water deprivation increases the body’s production of
endogenous opiates that create a euphoric state and has been associated with a
reduction in pain. The provision of intravenous hydration can have a negative impact
on quality of life by increasing pulmonary secretions, urinary output, nausea,
vomiting, and edema. As stated previously, the symptoms of dry mouth should be
managed with ice chips, lip balm, and moistened swabs.

Political and socio economic issues and concerns that affect nutrition care

Food security is of supreme importance in improving the nutritional status of many

millions of people who suffer from persistent hunger and under nutrition and many
others who are at risk of facing the same situation. There is a need to clarify the

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issues involved in achieving food security and to help formulate appropriate policies
and measures to strengthen it.

Ensuring household food security is a necessary condition for improving nutritional

status, but, by itself, it is not sufficient. The nutritional status of each member of the
household depends on several conditions being met: the food available to the
household must be shared according to individual needs; the food must be of
sufficient variety, quality and safety; and each family member must have good health
status in order to benefit nutritionally from the food consumed. Food insecurity leads
to much human suffering. In addition, it results in substantial productivity losses due
to reduced work performance, lower cognitive ability and school performance and
reduced income earnings. Food security and adequate nutrition are beneficial
outcomes in themselves, as well as important inputs to economic development. Food
security has three dimensions. First, it is necessary to ensure sufficient food supply
both at the national and local level. Secondly, it is necessary to have a reasonable
degree of stability in the supply of food both from one year to the other and within the
year. Thirdly, and perhaps the most critical, is to ensure that each household has the
physical and economic access to the food it needs.

An adequate food supply at the national level is necessary to achieve household

food security. Adequacy of national food supply depends on domestic food
production in relation to demand, trade policies, world food prices, foreign exchange
availability to import food from the international market and availability of food aid.
However, having an adequate food supply at the national level does not
automatically lead to food security for all households; there may still be poor
households that do not have the means to produce or the purchasing power to
procure the food they need. Inadequate access to food by the household can be
either chronic or transitory. Chronic food insecurity is a situation in which households
constantly lack adequate access to food. Transitory food insecurity is a condition in
which households do not have access to food at certain times; it arises from failure
of livestock and crop production, loss of employment, import difficulties, manmade
and natural disasters and other adverse circumstances. Household food security
issues differ in rural and urban settings. In urban areas, household food security
depends primarily on the level of income, often in the form of paid wages, in relation
to prices of food and other consumer goods. In rural areas, household food security
is most often determined by food availability and prices, which are commonly related
to agricultural productions, and by incomes which are determined by both on-farm
and off-farm employment opportunities. The number of the food-insecure people is at
present higher in rural areas, but the number of the urban food insecure is growing.
With urbanization growing rapidly in most developing countries, chronic food
insecurity among the urban poor is likely to become an increasingly important
problem in the future. National, regional and local availability of food depends
primarily on production, stockholding and trade. Shortfalls in food production and/or
in food availability through trade lead to food insecurity due to price rises or

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breakdown in distribution channels. At the household level, inadequate access to
food is primarily due to poverty; poor households do not have sufficient means to
secure the food they need. These are the households which suffer first and most
when food supplies fall or food prices rise. An array of policy measures, suited to the
problems and conditions prevail.

Poverty is a major determinant of chronic household food insecurity. The poor do not
have adequate means or "entitlements" (6) to secure their access to food, even
when food is available in local or regional markets. Furthermore, the poor are
vulnerable to shocks that are liable to slip them into temporary (transitory) food
insecurity. The ability of households to acquire adequate food may be affected by
events beyond their immediate control, for example, price shocks, war, deteriorating
terms of trade, domestic policy changes, pests, and climatic conditions such as
droughts, storms and floods.

Who Are the Food Insecure? Depending on factors such as agro-ecological

characteristics, access to land, diversity of income sources, and state of
development of the economy, food-insecure households can be members of different
socio-economic and demographic groups in different areas. Nevertheless, some
common characteristics of the food insecure emerge, of which poverty is a central
one. The poor face the most severe constraints in their own food production and in
their access to food from markets, which renders them vulnerable to food security
crises. A number of common sociodemo graphic characteristics emerged from a
recent comparative study that looked at income source patterns of malnourished
rural poor in 13 survey areas in Africa, Asia, and Latin Americe2'2. Food-insecure
households tended to be larger and to have a higher number of dependents, and
they tended to have a younger age composition. Ownership of land or access to
even small pieces of land for farming had a substantial impact on the food security
status of rural households, even when income level is controlled for; the prevalence
of food insecurity tended to be higher among landless or quasi-landless households
who were much more dependent on other sources of income than farm income and
on the diversification of the rural economy; Women's income had an important
influence on the food security status of the household, and women-controlled income
was more likely to be spent on food and nutrition than male-controlled income; The
relationship between income diversification and malnutrition is difficult to generalize--
the relationship is context- and location-specific and a result of household coping
strategies. A typology of food-insecure households needs always to be aware of this
location and context specificity. Typically, the food insecure, spend a high share of
their income on staple food consumption and/or allocate a high share of their
production resources to subsistence food production in normal years; yet, they may
barely meet their needed levels of dietary intake. Different types of risks affect
various groups of food-insecure households and their members differently

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Food security and nutritional well-being arising from food consumed by households
is determined by at least five interrelated factors:

 Availability of food through market and other channels, which is a function of

factors discussed above;
 Ability of households to acquire whatever food the market and other sources
have to offer, which is a function of household income levels and flows and
the resource base for subsistence farming;
 Desire to buy specific foods available in the market or to grow them for home
consumption, which is related to food habits, intra-household income control,
and nutritional knowledge;
 Mode of food preparation and to whom the food is fed, which is influenced by
income control, time constraints, food habits.
 Nutritional knowledge; and gum Health status of individuals, which is
governed by the nutritional status of the individual, nutritional knowledge,
health and sanitary conditions at the household and community levels, and
care, among others.

Again, each of these determinants has specific risk attributes that determine food
security and nutritional risk.

Food security and nutritional well-being are connected through the actual utilization
of food by individuals, as determined by some of the five above-mentioned factors
(for example, health, the composition and energy density of diet, mode of processing
and preparing food, and, for infants, the extent of breast-feeding and general child
care). While concentrating on the issue of improving household food security, an
essential step toward securing good nutritional status, this paper does not cover
these other important factors identified here, which, together with food security,
determine the ability to achieve good nutritional status.

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 TOPIC 8

FILIPINO CULTURE, VALUES, PRACTICES, AND BELIEFS APPLICABLE TO

NUTRITION

Introduction

As you get to know a new patient, especially where there is a language or

culture barrier, make sure you are asking questions that give you as complete
an understanding as possible. For example, in Chinese culture, understanding
the concept and importance of hot and cold foods and how they are utilized to
regulate health at an individual level will help you better connect with your
patient to drive behavior change. Likewise understanding the dietary
restrictions of religious beliefs such as those observed by both Islamic and
Jewish faiths in their prohibition of pork or Hinduism in its prohibition of beef will
help build insightful and trusting relationships.  Having this information will allow
you to give more personalized advice on when to take medications, how to
regulate blood sugars, or how to modify eating behaviors.

Learning Outcome

After the discussion the students should be able to:

1. Customized nutrition plan based on Philippine Culture, values, practices, and

beliefs.
2. Demonstrate nursing core values in implementing nutrition plan

Learning Content

1. Cultural Aspects of Dietary Planning

2. Filipino Dietary Practice

3. Core Values of Nursing as applied to Nutrition and

Dietetics

Culture and nutrition

Recognizing that many cultures tie their eating habits to the customs of their families
can also be an important concern. Try asking, through your interpreter, if the family
all eats the same food together most often, or if there are modifications for different
individuals. Does the family follow any religious traditions or holidays that create
modifications to their traditional diet? This can help you determine whether

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eliminating or changing food in one’s diet would create undue strain on the family’s
mealtime rituals. Changing portion size, for instance, might be a more appropriate
and less disruptive suggestion.

Most importantly, do everything you can to enlist the patient in developing his or her
own plan once they understand the health challenges they face. Different cultures
may encourage or frown upon consumption of different foods by individuals who
belong to their groups. Also the consumption of different foods at different stages of
life may be actively encouraged or discouraged.

This is due to the benefits and dangers of consuming these foods at certain times of
life and in certain conditions. For example most cultures will not approve of the
consumption of alcohol during pregnancy or lactation. This is due to the adverse-
affects produced by this drink. Foods and nutrition may also be affected by culture,
with respect to different beliefs within the culture.

For example:

 In the Hindu and Buddhist religions the consumption of both pork and beef is
frowned upon. This is because it is considered to not be clean meat. Also
ancient Hindu scriptures prohibit the eating of these meats. As a result of this
the large majority of Hindus and Buddhists (roughly 90%) have taken this rule
to the extreme. They refuse to eat any meat at all and are strict vegetarians,
despite being allowed to eat chicken and lamb.

 Conversely only the consumption of pork and not beef is prohibited for the
same reasons in the Islamic religion and Judaism. However all other meats
consumed in these religions must be halal and kosher respectively. This
means that special prayers are performed in order to make the eating of these
animals acceptable.

 In stark contrast Christianity and the Catholic religion allow the consumption
of any types of meat without the need for any kind of repentance to God in the
form of prayer.

 Also at the other extreme to these religions the Jain religion does not allow
the eating of any meat and any vegetables grown beneath the soil. 

Within certain religious groups there are different levels of acculturation. This means
there is a large diversity with respect to the extent certain individuals follow the
teachings of their religion. In some cases this diversity may result from the patient’s
own interpretation of their particular religion. For example some individuals may be
devoutly religious and follow their religion strictly according to the teachings. Also
some individuals may not be as religious to such a degree and will tend to follow
their religion more loosely. In the case of the patients I interviewed, only the first

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patient was very religious. This resulted in her food choices being greatly influenced
by religion.

Negative and Positive Impact of culture in nutrition and diet

Different cultures can produce people with varying health risks, though the role of
diet is not always clear. For example, African-Americans and many Southerners are
at greater risk for ailments such as heart disease and diabetes, but Southern-style
fried foods, biscuits and ham hocks might not be the only culprits. Income levels,
limited access to healthier foods and exercise habits might play a role as well.
Menus stressing lower-fat foods and lots of vegetables, such as those of many Asian
cultures, can result in more healthful diets, even reducing the risks for diseases such
as diabetes and cancer.

Cultural Shifts

As people from one culture become assimilated into another, their diets might
change, and not always for the better. A good example is the shift away from
traditional eating patterns among Latinos in the United States. Besides the well-
known emphasis on ingredients such as hot chiles and cilantro, traditional, nutritious
Latino meals include corn, grains, tubers such as potatoes and yucca, vegetables,
legumes and fruits. But a shift to a higher-fat, Americanized diet has raised the
obesity rate among Latinos and the health risks that go with it.

Mediterranean Example

How would you like a Mediterranean cruise? Not possible for everyone, but certain
Mediterranean cultures feature diets so healthful that lots of people try to emulate
them. According to the Cleveland Clinic, nutrition experts years ago took note of
typical diets in regions such as Crete, other parts of Greece and southern Italy,
where life expectancy was high and heart disease rates were low. The
Mediterranean diet includes seasonal foods with minimal processing, plenty of
vegetables and whole grains, fresh fruit for dessert instead of sugary sweets, olive oil
as the main fat, and moderate amounts of dairy products, fish and poultry.

Healthier Diets

Enjoy your culture and the foods that make it special, but look for ways to tweak diet
traditions to make them more healthful. The American Academy of Family
Physicians and American Cancer Society suggest you reduce your risks for chronic
disease by eating more fruits and vegetables, limiting alcohol consumption, avoiding
high-fat and sugary foods, and cutting back on processed foods and red meat. Try
substituting less-fattening ingredients — for example, reduced-fat cheese in tacos,
veggies instead of meat in lasagna or fat-free yogurt in raita sauce. And include
exercise in your personal and family routines, aiming for 30 to 60 minutes of exercise
on most days.

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Filipino Dietary Practice

Filipino food is colorful and distinctive due to the blended influences of Malaysian,
Polynesian, Spanish, and Chinese cuisines. There are three principles of Filipino
cooking: never cook any food by itself, fry with garlic in olive oil or lard, and foods
should have a sour-cool-salty taste. In place of the traditional clay pot, a large wok
called a kalawi is used for frying foods. Fried foods are allowed to absorb more fat
than is typical of other Asian cooking. Rice, steamed or fried, forms the foundation of
the diet. Rice flour is used to make noodles and bread. Noodles made of mung
beans or wheat are also common, prepared with a cooked protein (chicken, ham,
shrimp, pork) in a soy and garlic-flavored sauce. Vegetables are mixed into stews,
stir fries, and soups or braised and served as an entrée or a side. The amount of
meat, poultry, or fish a family eats depends on economic status and are added as
available to soups, stews, mixed dishes, and egg rolls (lumpia). All parts of the
animal are used in cooking including the skin, blood, and organs. Rural Filipinos
make one of the few native cheeses in Asia from water buffalo (carabao) milk. The
water buffalo milk is also often used in desserts. Fermented fish paste or sauce is a
popular seasoning used instead of salt. To add a sour-cool taste to foods, palm
vinegar or a paste made from tamarind or kamis (cucumber-like vegetable) is used.

A Filipino specialty, called kinilaw, uses sour ingredients to marinate and pickle raw
foods including fruit, vegetables, meats, organs, and seafood. Lime wedges and
chili-flavored vinegar are frequently offered on the table so that diners may add
desired levels of saltiness or sourness to their food. The coconut is widely used in
Filipino cooking as a vegetable or to make beverages, desserts, and sauces.
Common desserts include custard (leche flan) and a parfait-like dessert made of
shaved ice, coconut milk, mung beans, purple yam pudding, palm seeds, corn
kernels, pineapple jelly, and other ingredients (halo-halo).

Regional cooking styles in the Philippines are divided into four regions: Luzon,
Bicolandia, the Viscayan Islands, and Mindanao. Luzon is ethnically diverse and the
cuisine is strongly influenced by the Spanish. In the northern areas, ocean fish and
ample amounts of anchovy sauce and shrimp paste are commonly eaten. Boiling
and steaming are the typical cooking methods, and spinach like greens (saluyot) and
drumstick plant leaves (sili) are particularly popular.

The central region is known for growing rice and for its freshwater fish. Dishes are
richly sauced and flavored with onions and garlic. The most common cooking
technique is stir-frying. Coconut products and tropical fruits are highly popular, and
sweetened rice dishes are a specialty. Bicolandia is ethnically homogenous with
culinary influences from Malaysian and Polynesian styles of cooking.

Foods tend to be very spicy due to use of chile peppers, but the spice is balanced
with coconut milk and cream. The fare in the Viscayan Islands includes abundant
use of seafood, shrimp paste, and seaweed. Specialty candies and pastries are

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common due to the sugarcane plantations in the area. The cuisine of the Mindanao
region is influenced by Indonesia and Malaysia. Little pork is consumed, as much of
the region is Muslim. Sauces made from peanuts and chiles, curries, and other spicy
fare are very popular.

At the center of the Filipino family is the extended family including all paternal and
maternal relatives. Familial kinship may also include friends, neighbors, and fellow
workers. Community obligations are initiated through shared Roman Catholic rituals
and include shared food, labor, and financial resources. Elders are respected, and
children are spoiled and adored by the family until the age of six. Children are
expected to be obedient, to contain their emotions, to be very polite, to be quiet and
shy, and to avoid all conflict.

Many Filipinos believe that health requires personal harmony with the supernatural
world, nature, society, and family. Three practices promote balance and good health:
heating (balance of hot and cold), protection (safeguards body from natural and
supernatural forces, a layer of body fat for example), and flushing (cleansing the
body of impurities).

Nutrition Facts:

The traditional Filipino diet is higher in total fat, saturated fat, and cholesterol than
most Asian diets. Overweight can be associated with health and caretakers may try
to overfeed babies. Southeast Asians may calculate age on a lunar calendar, starting
with being one year at birth. This difference can distort use of standardized growth
curves.

Lactose intolerance is common in Filipinos. Health conditions that may compromise

nutritional status include tuberculosis, intestinal parasites, malaria, and Hepatitis B.

Possible Deficiencies

 Calcium – Calcium is needed to build strong bones and teeth. It also plays a
role in blood clotting, muscle contraction, and nerve-cell communication. In
the long term, dietary intakes well below the recommended levels may impact
bone development. Bones increase in size and mass during childhood and
adolescence, therefore adequate calcium and vitamin D should be consumed
throughout childhood into early adulthood.

 Iodine – Iodine is needed for production of thyroid hormone. Deficiency of

iodine can lead to development of an enlarged thyroid called a goiter,
hypothyroidism, and mental retardation in children whose mothers were iodine
deficient during pregnancy.

 Iron – Iron is necessary for oxygen delivery to cells and regulation of cell
growth. Iron deficiency develops gradually and is commonly seen in women of

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 childbearing age and children. A lack of iron results in an insufficient supply of
oxygen to cells eventually causing anemia, fatigue, poor work performance,
slow cognitive and social development in children, and decreased immunity.

 Selenium – Selenium is an essential mineral that acts as a protective

antioxidant in the body and regulates thyroid hormone. Keshan disease is a
cardiac problem that can occur in selenium-deficient children and mothers.
Selenium deficiency often accompanies iodine deficiency.

 Vitamin A – Vitamin A plays a critical role in healthy vision, growth and
development, and immune function. Vitamin A deficiency is common in
developing countries and is often accompanied by zinc deficiency. Symptoms
of deficiency include blindness, diminished ability to fight infections,
decreased growth rate, and slow bone development. Vitamin A helps mobilize
iron from its storage sites, so a deficiency of vitamin A limits the body’s ability
to use stored iron. This results in an “apparent” iron deficiency because iron
levels in the blood are low even though body stores are normal.

 Zinc – Zinc is involved in many important processes in the body. Symptoms

of zinc deficiency include delayed growth, loss of appetite, impaired immune
function, hair loss, diarrhea, delayed sexual maturation, eye and skin lesions,
delayed wound healing, taste abnormalities, and mental fatigue.

Common Foods:

Milk/Milk Products – evaporated milk (cow, goat), white cheese (carabao, made from
water buffalo milk)

Meat/Poultry/Fish – beef, carabao, goat, pork, monkey, variety meats (liver, kidney,
stomach tripe), rabbit, chicken, duck, pigeon, sparrow, anchovies, bonita, carp,
catfish, crab, crawfish, cuttlefish, dilis, mackerel, milkfish, mussels, prawns, rock
oyster, salt cod, salmon, sardines, sea bass, sea urchins, shrimp, sole, squid,
swordfish, tilapia, tuna

Eggs/Legumes – chicken and fish eggs; black beans, black-eyed peas, chickpeas,
lentils, lima beans, mung beans, red beans, soybeans, white kidney beans, winged
beans

Cereals/Grains – corn, oatmeal, rice (long- and short- grain, flour, noodles), wheat
flour (bread and noodles)

Fruits – apples, avocados, banana blossoms, bananas (100 varieties), bread fruit,
calamansi (lime), citrus, coconut, durian, grapes, guava, jackfruit, Java plum, litchi,
mangoes, melons, papaya, pears, persimmons, pineapples, plums, pomegranates,
pomelo, rambutan, rhubarb, star fruit, strawberries, sugar cane, tamarind,
watermelon

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Vegetables – amaranth, bamboo shoots, bean sprouts, beets, bitter melon, burdock
root, cabbage, carrots, cashew nut leaves, cassava, cauliflower, celery, Chinese
celery, drumstick plant, eggplant, endive, green beans, green papaya, green
peppers, hearts of palm, hyacinth bean, kamis, leaf fern, leeks, lettuce, long green
beans, mushrooms, nettles, okra, onions, parsley, pigeon peas, potatoes, pumpkins,
purslane, radish, safflower, snow peas, spinach, sponge gourd, squash blossoms,
winter and summer squashes, sugar palm shoot, swamp cabbage, sweet potatoes,
taro, tomatoes, turnips, water chestnuts, watercress, yams

Seasonings – atchuete (annatto), bagoong, baggong-alamang, chile peppers, garlic,

lemon grass, patis, seaweed, soy sauce, turmeric, vinegar

Nuts/Seeds – betel nuts, cashews, palm seeds, peanuts, pili nuts

Beverages – soymilk, cocoa, coconut juice, coffee with milk, tea

Fats/Oils – coconut oil, lard, vegetable oil

Sweeteners – brown and white sugar, coconut, honey

Meal Patterns:

Three meals a day with a mid-morning and late afternoon snack (called meriendas)
is the traditional pattern of eating. Garlic-fried rice or bread with eggs or broiled fish,
sausage, or meat, plus hot chocolate or coffee is an example of a typical breakfast.
Sweet, cheesy rolls called ensaymada are also especially popular for breakfast.
Lunch and dinner are both large meals of similar composition that include soup, rice,
a crispy or chewy dish, a salty dish, a sour dish, a noodle dish, and often, an adobo
dish. Fresh fruit or dessert concludes the meal. Courses are served consecutively if
the meal features mostly Spanish-style dishes. Conversely, all courses are served
together, including dessert, if the meal features Filipino-style dishes. Snacks may be
small or large. Almost all foods may be eaten as snack, except rice, which is served
only at meals. Common snacks include fritters, pastries, fruits, ensaymadas, or
lumpia.

Dining tables are frequently equipped with lazy Susan turntables so that all food is
accessible to everyone. Tradition is that no one starts eating until the eldest male
starts the meal. The western style of dining with forks, knives, and spoons is
common, however, the use of just forks and spoons is also typical. The spoon is
used to hold down the food while the fork is used to pull bits away, then the spoon is
used to push food onto the fork for eating. In rural areas, fingers (of the right hand
only) are more commonly used for dining. Small mounds of rice are rolled to form a
ball that is dipped into sauce then pressed into meat or poultry and popped whole
into the mouth. Taking the last bits of food from the central platter is considered poor
etiquette.

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Predominantly of Catholic faith, Filipinos celebrate many religious festivals and
saints’ days. Abundant food served buffet-style with roasted pig as the centerpiece is
customarily served on all special occasions.

Filipino food and Culture

Traditional food and dishes

The food and culture of the Philippines are largely influenced by Spanish, Chinese
and American traditions. White rice is the main food in the diet and it is usually
served three times per day. Fish is the primary protein source in the diet. Vinegar,
soy sauce, salt, fish sauce and fermented fish are traditional flavorings used in
Filipino cuisine. Philippine adobo is often dubbed the national dish, but varies from
the adobo served in other cultures. In the Philippines, adobo refers to foods stewed
in a broth of garlic, vinegar, bay leaf and peppercorns and is made with chicken, pork
or both.

Holidays and Special Occasions

More than 80 percent of Filipinos identify as Catholic, with almost percent

identifying as another Christian denomination. Food is often the center point of
celebrations and the Philippines are known for a long Christmas season. Food
choices for the holidays vary by island and family economics, however, cocido
(meat, sausage, salt pork and ham with cabbage and beans) is considered a more
elaborate and expensive meal suitable for Christmas. Tinubong (rice cake cooked in
a bamboo tube) is a common Christmas treat or dessert.

Traditional Eating Patterns

Fresh fish is often caught daily and many families have gardens. Traditionally, a clay
pot is used for steaming rice and stewing other foods. A kalawi (similar to a wok) is
commonly used for sautéing. Courses of a meal may be served consecutively, if
Spanish in origin, or simultaneously, including dessert, if the dish is of Philippine
origin. Generally, the eldest male starts the meal, and others follow. Because soups,
stews and mixed dishes are common, forks are spoons are frequently used, but
knives may not be present on the table. Typically, three meals and two snacks, one
mid-morning and one mid-afternoon, are eaten daily.

Traditional Health Beliefs

 Flushing, heating and protection are the key elements to traditional health
beliefs. Flushing rids the body of debris, heating regulates the internal
temperature and protection involves safeguarding the body from natural and
supernatural forces. Being overweight is thought of as such protection and a
layer of fat on the body denotes resistance. Filipinos will use home remedies
and herbal medicine first. These may include drinking boiled ginger for a sore
throat and boiling corn hair in water and drinking it to promote urination. A

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 hilot, is a traditional practitioner sought for pain relief, and offers treatment
along the lines of chiropractic and massage. Filipinos will seek the advice or a
traditional healer or family elder prior to that of a physician and usually only
seek a doctor when the illness has advanced and home remedies have failed.

Current Food Practices

Rice and fish are still the staple foods in the Philippines,despite the availability of
fortified rice and iodized salt, micronutrient deficiencies persist. Anemia,
hypothyroidism and osteoporosis are prevalent. In urban areas, more foods are
available, including some American-style fast food and convenience foods, like
cereals, and obesity is on the rise. First generation Filipino-Americans see
themselves as more Filipino than American. However, most report enjoying
American food just as well as traditional Filipino food and consume them equally.
While the use of butter as a spread is still uncommon, bakery foods, cereals and
waffles are commonly consumed, in addition to traditional white rice. Dairy products
are more affordable in the U.S. and have been embraced, as have processed meats.
Due to increased availability, Filipino-Americans eat a better variety of vegetables,
but rarely eat them raw. Additionally, fast food consumption and increased portions
of calorie dense foods are associated with Filipino dietary acculturation. Proper
nutrition plays a big role in disease prevention, recovery from illness and ongoing
good health. A healthy diet will help you look and feel good as well. Since nurses are
the main point of contact with patients, they must understand the importance of
nutrition basics and be able to explain the facts about healthy food choices to their
patients. Nutrition classes provide the information necessary to sort the fact from
fiction about healthy eating and pass that knowledge on to their patients. Not only
must nurses be able to explain the ins and outs of a healthy diet, they must also lead
by example.

HOW DOES NUTRITION RELATE TO HEALTH?

Healthy food choices are vital to preventing illness, particularly chronic illnesses such
as diabetes and heart disease. Nurses work in a variety of healthcare settings, not
just hospitals. While nurses in hospitals may focus more on the dietary concerns of
patients recovering from illnesses, community nurses focus more on prevention.
Nurses who work at schools or community centers can often provide nutritional
education to the public to prevent chronic conditions.

It is important that nurses understand proper nutrition as it relates to recovery as

well.

Proper nutrition is not only important for preventing disease, it is also crucial to the
recovery process. According to an article by Michael Henning titled "The healing of
the body can take place only when the nutrients that provide the building blocks for
repair are present." Due to the lack of trained nutritionists, the responsibility of
educating patients on healthy eating habits often falls to attending nurses. They can

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put together diet plans for patients to take home and use long after they leave the
hospital. Protein is essential to the healing process: "Fats and carbohydrates are
also important in helping wounds to heal. They stop your body from using protein as
an energy source, allowing it to be used to heal tissue."

Not only should people recovering from illness make sure they eat right, they also
need to make sure they are eating enough. Many illnesses and treatments can
cause a loss of appetite -- including anything from a common cold to chemotherapy.
Weight loss can increase your chances of infection, notes Victoria Taylor, a dietician
with the British Heart Foundation. Taylor suggests "having more frequent meals, or
little snacks throughout the day."

HOW CAN NURSES TEACH PATIENTS ABOUT A HEALTHY DIET?

There are many ways nurses can teach their patients about proper nutrition as it
relates to their health. Presentations at community health centers are crucial to
community health. A nurse with the right knowledge can prepare a PowerPoint
presentation to show for a group of seniors during a health fair. They can also give
the attendees literature to take home for further study and guidance. Similarly, a
school nurse can present students with the facts about healthy nutrition during a
school assembly as well as giving them brochures to take home.

Nurses who work in hospitals and clinics are likely more concerned with nutrition as
it relates to recovery from illness, surgery or other treatments. Nurses can talk to
patients at the bedside and explain the special meals they have at the hospital that
aid recovery, as many patients will be on special diets during their stay. These
nurses can also gather informative and accurate literature to give patients when they
are discharged. Healthy eating goes far beyond the hospital, especially if the patient
plans to stay out of the hospital.

LEAD BY EXAMPLE (PRACTICE WHAT YOU PREACH)

According to an article titled "Healthy Eating for Healthy Nurses: Nutrition Basics to
Promote Health for Nurses and Patient" published in The Online Journal of Issues in
Nursing, "When healthcare professionals, such as nurses, care for their own health,
it is reasonable to think that this will help them to better care for patients." Nurses
often find themselves working a mixed schedule -- nightshifts for a few days and
then a dayshift a day or two later. Add to that the stress of the job itself, and poor
food choices may become the norm. Patients, who are likely getting information
about nutrition from their nurses, are likely to be aware of the "health habits" of those
nurses. As noted in The Online Journal of Issues in Nursing article, "[patients] were
more confident to receive diet and exercise education from a normal weight nurse."
As you can see, the importance of nutrition is clear from both sides on the healthcare
equation.

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Teaching and Learning Activities

ACTIVITY

1. Interview Parents/Grandparent’s or an elder regarding the old ways and

beliefs in nutrition. Collate all the information and compare.

2. Make a written report- Do this in a separate sheet of paper.

3. Using the data you have collected make a video presentation, this will be
submitted accordingly and in a timely manner.

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