One of the biggest benefits of attending minority nursing association conferences—in addition to all the networking opportunities, educational programming, CEUs and camaraderie, of course—is getting to visit exhibits filled with booth after booth offering free or low-cost minority health resources that you can take home and start using in your practice right away. For readers who were unable to attend this summer’s National Association of Hispanic Nurses and National Black Nurses Association annual conferences, MN’s third annual Fall Resources Roundup highlights some of the more interesting items we brought back from these events—and we don’t mean all those cool freebie pens.
Por Tu Familia
The American Diabetes Association’s Por Tu Familia program offers a wide variety of culturally appropriate bilingual resources designed to educate Latinos about diabetes prevention, treatment and management. These tools include everything from printed materials—brochures, recipe books, nutrition guides and food/exercise journals—to outreach activities such as nutrition and exercise workshops and a feria de salud (street health fair). For more information and free materials: 1-800-DIABETES
Recreational Drugs and HIV Antiretrovirals: A Guide to Interactions for Clinicians
What happens when HIV/AIDS patients who are on complicated antiretroviral drug regimens are also using recreational or illicit drugs, such as alcohol, marijuana, cocaine or even Viagra? Sometimes nothing; but in some cases, the resulting drug interactions can cause adverse, even dangerous, effects. Recreational Drugs and HIV Antiretrovirals: A Guide to Interactions for Clinicians, a new reference guide from the New York/New Jersey AIDS Education Training Center, does not condone the use of illicit drugs but is intended to provide advice that may reduce harm to patients who use these substances in conjunction with antiretroviral agents. Downloadable from: http://www.nynjaetc.org.
47 Healthy Soul Food Recipes
“Family Reunion Black-Eyed Pea Salad,” “Slow-Cooker Collards” and low-calorie, low-fat corn bread made with egg substitutes and canola oil are just a few of the 47 Healthy Soul Food Recipes available in this “cookbooklet” from the American Stroke Association. Developed as part of the ASA’s ”Power to End Stroke” African American outreach campaign, the booklet also contains easy-to-read information about stroke warning signs, risk factors, optimal blood pressure and cholesterol levels, and diabetes screening, plus health promotion messages from black entertainment icons Tom Joyner and Alexis Prater. Copies can be ordered from: http://www.StrokeAssociation.org.
Medicare Prescription Assistance Handouts
Many senior citizens who are having trouble affording their Medicare prescriptions are unaware that they may qualify for a Social Security program that provides additional prescription assistance. To spread the word about this benefit in African American and Hispanic communities, the Centers for Medicare & Medicaid Services (CMS) has created easy-to-read patient handouts that explain in simple terms and pictures how to apply for extra help with prescription drug costs. Downloadable from: http://www.medicare.gov (click on “Find a Medicare Publication,” then search for publication ID# 11318-AA).
“You’ve Got the Power!”
“You’ve Got the Power!” is a new public awareness campaign launched by the National Medical Association’s Project I.M.P.A.C.T. (Increase Minority Participation and Awareness of Clinical Trials). It offers a variety of persuasively written patient education materials—including a brochure, fact sheet and bookmark—that explain why it’s so important for people of color to take part in clinical trials. The materials also address cultural fears and misgivings minority patients may have about participating in research studies. For more information and free materials: http://www.impact.nmanet.org or (202) 347-1895.
“In Control: Living a Healthy Life with Diabetes” is an award-winning 20-minute DVD created to educate African American and Hispanic diabetes patients, their families and caregivers about the devastating impact of this disease in their communities and the importance of actively controlling their diabetes through day-to-day self-management. Produced by a minority nurse, Cynthia Degazon, PhD, RN, professor emerita at Hunter Bellevue School of Nursing, the DVD focuses on real-life stories of people of color living with diabetes who are learning to manage their disease by making healthier lifestyle choices. Copies are available from: Dr. Cynthia Degazon, [email protected]“>[email protected].
What It Means to You
According to the landmark 2004 Surgeon General’s Report on Bone Health and Osteoporosis, more than 10 million Americans over the age of 50 have osteoporosis, with Asian and Hispanic women at particularly high risk. The Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You condenses the original 400-page report into 24 pages of osteoporosis prevention and bone health tips written in easy-to-understand, plain language. It is available in English, Spanish and Chinese. To order copies: http://www.osteo.org.
“Just Like Winter, Meth is Here”
In response to the growing crisis of methamphetamine addiction in Indian Country, the Office of National Drug Control Policy has partnered with the Bureau of Indian Affairs, the National Congress of American Indians and other organizations to launch the first ever anti-meth public service ad campaign targeted to American Indian and Alaska Native populations. The campaign offers several culturally sensitive print and radio ads that promote taking pride in Native culture as an alternative to using meth.
A love of nature and the importance of living a simple, natural life are the basis of Hinduism, a faith that originated in India and is generally acknowledged to be the world’s oldest and third largest religion. Like Buddhism, the Seventh-day Adventist Church and other religions that promote a vegetarian lifestyle, the Hindu faith encompasses a number of health beliefs and dietary practices arising from the idea of living in harmony with nature and having mercy and respect for all of God’s creations.
Followers of the Hindu religion, which is practiced primarily in India, Nepal and Sri Lanka, believe that the body is made up of natural elements: earth, air, fire, water, etc. The proper balance of these elements indicates good health, while an imbalance indicates the opposite. Hindus believe self-control and meditation is the path to health, with prayer to the Almighty God being the last resort. For many Hindus, yoga is a means by which to bring the integration of the body, mind and intellect together in order to achieve perfect harmony or alignment.
The four Vedas (which means “the Wisdom and the Knowledge”) are among the most important of the Hindu holy books. For devout believers, these sacred texts address every aspect of their lives that are controlled by their faith, including their daily practices, their yearly calendar and their use of water in acts of worshipping. For Hindus, water is believed to be a purifier and a rejuvenating agent for religious acts, as evidenced, for example, in the traditional practice of bathing in sacred rivers during pilgrimages.
The Hindu Dietary Code
Devout Hindus believe that all of God’s creatures are worthy of respect and compassion, regardless of whether they are humans or animals. Therefore, Hinduism encourages being vegetarian and avoiding the eating of any animal meat or flesh. However, not all Hindus choose to practice vegetarianism, and they may adhere to the religion’s dietary codes in varying degrees of strictness. For example, some Hindus refrain from eating beef and pork, which are strictly prohibited in the Hindu diet code, but do eat other meats.
Some Hindu Sayings and Beliefs Related to Health and Diet Live a natural, healthy life—i.e., be like the birds and animals. “The treatment is a learning process, but sometimes an old patient is worth more than a young doctor.” In other words, knowledge, wisdom and experience are valuable to the process of staying healthy. Showing care for what you eat can save your body and mind. Eat moderately and consume simple, pure, healthy foods (a Sattvic diet) even when not fasting.
Like Buddhists, Hindus believe that food affects both body and mind. Food is considered to be a source of the body’s chemistry, which affects one’s consciousness and emotions. Thus, expression of the soul depends on the body, which depends on the food. A proper diet is considered vital for spiritual development in Hinduism. The Hindu diet code divides food into three categories, based on the food’s effect on the body and the temperament:
Tamasic food is leftover, stale, overripe, spoiled or other impure food, which is believed to produce negative emotions, such as anger, jealousy and greed.
Rajasic is food that is believed to produce strong emotional qualities, passions and restlessness in the mind. This category includes meat, eggs, fish, spices, onions, garlic, hot peppers, pickles and other pungent or spicy foods.
The most desirable type of food, Sattvic, isfood that is non-irritating to the stomach and purifying to the mind; it includes fruits, nuts, whole grains and vegetables. These foods are believed to produce calmness and nobility, or what is known as an “increase in one’s magnetism.”
Hindus believe that for true service to God, purity of food is necessary to maintain the desirable state of mind that leads to enlightenment. Food is consumed not only to survive but also to stay healthy and maintain mind/body equilibrium. By eating a purer quality of food, such as a Sattvic diet, and regulating food consumption, one can ensure a pure heart, long life, cheerful spirit, strength, health, happiness and delight. Good and pure food promotes a peaceful—not agitated—mind, which is needed to see the Truth as the Truth. Sin, or an agitated state of mind, prevents the journey to moksha (divine supreme knowledge, which leads to freedom from the cycle of birth, life, death and rebirth).
Some specific Hindu dietary customs and practices include the following:
A true devotee will refuse to accept any food that is not offered first to God. Gaining God’s blessing before consuming the food is essential. Hindus may do this is by placing their daily food before the particular deities they worship and by reciting shlokas(prayers). Once the food is offered to God, it is eaten as prasador blessed food.
Before starting any daily meal, a devout Hindu first sprinkles water around the plate as an act of purification.
Five morsels of food are placed on the side of the table to acknowledge the debt owed to the devta runa (divine forces) for their benign grace and protection.
For a child’s birthday celebration, the sacred symbol “OM” is added onto the birthday cake along with “Happy Birthday.” Also, a lamp is lit instead of having the child blow out the candles. In the Hindu faith, lighting a lamp is symbolic of new life, a new beginning or the spreading of knowledge.
The Practice of Fasting
Some Hindus practice the tradition of fasting during special occasions, such as holy days, new moon days and festivals. As is also the case in a number of other religions, fasting is seen as a way of staying close to God and attaining a close mental proximity to Him. Hindus fast in various ways, depending on the individual: They may choose to not eat at all during the fasting period, or to eat only once, eat only fruits or restrict themselves to a special diet of simple foods.
Fasting is believed to help reinforce control over one’s senses, squelch earthly desires and guide the mind to be poised and at peace. Hindus also believe that when there is a spiritual goal behind fasting, it should not make the body weak, irritable, or create an urge to later indulge. Rather, rest and a change of diet during the fasting time is considered to be very good for the digestive system and the entire body. The idea is that every system needs a break and an occasional overhaul to work at its best.4
Health Considerations of the Vegetarian Diet
There is a myth that vegetarians suffer from vitamin deficiencies. The truth is that all needed nutrients are found in vegetables, fruits and nuts when eaten in sufficient amounts; the only exception is vitamin B12. To overcome this potential deficiency, which can cause anemia and other disorders, vegetarians need to markedly increase their protein intake. According to the recommendation of the American Dietetic Association (ADA), vegetarians should increase their consumption of rice milk, soy milk, yeast extracts and breakfast cereals to ensure a sufficient intake of vitamin B12.
Ask the Cultural Competence Expert Minority Nurse’s cultural competence expert, Gihan ElGindy, MSN, RN, is an internationally recognized authority on cross-cultural issues in nursing. This column is designed to answer your questions about incorporating cultural competence into your nursing practice and resolving cultural conflicts in today’s diverse health care workplace. Do you need advice on how to provide culturally sensitive care to patients from a particular ethnic or religious background? Are you looking for ways to increase understanding and acceptance of cultural differences in your work environment? Our expert can help! Send your Cultural Competence Q&A questions to [email protected].
Some vegetarians refrain from eating meat, fish or fowl but do consume eggs and/or dairy products. In contrast, a vegan diet is a total vegetarian diet that excludes any and all animal products (i.e., no meat, eggs and dairy). Therefore, vegans generally have a lower calcium intake than non-vegetarians, but they may have lower calcium requirements as well. Vegans are advised to increase their intake of Omega-3 fatty acids found in flax seed, walnuts, soybeans and dark green vegetables.
The ADA is just one example of a major health organization that recognizes that a well-planned vegetarian or vegan diet can reduce the risk of many chronic conditions, such as heart disease, obesity, diabetes, asthma, high blood pressure and cancer. Because vegetarians are less susceptible to major diseases, they can live healthier, longer and more productive lives, with fewer visits to doctors, fewer dental problems and lower medical bills.
Here are some additional health benefits of the vegetarian diet:
Food is easier to digest, provides a wider ranger of nutrients and requires less effort to purify the body from its wastes.
Vegetarians’ immune systems are stronger, their skin is less flawed and their bodies are more pure and refined.
Finally, because meat is expensive compared to fruits, vegetables, etc., a vegetarian diet can also have financial benefits for low-income populations. Unfortunately, lack of sufficient access to food stores that sell good quality fresh produce continues to be a serious health problem in disadvantaged communities.
Editor’s Note: Previous articles in the culturally competent dietary assessments series, including “Meeting Jewish and Muslim Patients’ Dietary Needs” and “Understanding Buddhist Patients’ Dietary Needs,” are available online.
Last summer I enjoyed the honor and great privilege of presenting a poster session with my former colleague Anderson Torres, PhD, LCSW-R, at the 34th Annual Conference of the National Association of Hispanic Nurses (NAHN). The conference was held in San Antonio, Texas—a city known for good Southwestern food, intoxicating Mariachi and Tex-Mex music and warm, engaging Texan hospitality.
NAHN, founded by Dr. Ildaura Murillo-Rohde in 1975, is a professional nursing association committed to improving the health of Hispanic patients and communities and to increasing educational, professional and economic opportunities for Hispanic nurses. Although he is a social worker, not a nurse, Anderson was one of the core group members who helped in revitalizing and expanding our local NAHN chapter here in New York City.
The subject of our poster presentation was the correlation between diabetes and Alzheimer’s disease in the Hispanic community. Alzheimer’s is a topic close to Anderson’s heart, since his abuela (grandmother) suffered from this heartbreaking condition. The Alzheimer’s Association defines it as an irreversible, progressive disease that slowly destroys memory, reasoning skills and, eventually, the ability to carry out the simplest tasks of daily living. Our presentation focused on the effects of diabetes and Alzheimer’s disease among Hispanics and on the role diabetes plays in increasing the risk of dementia in this vulnerable populations. We also presented culturally competent, patient-centered strategies that our Hispanic community can implement in real-life settings to promote healthy behavior change and encourage patients to take control of their health.
Before I describe our presentation in detail, let me explain that for nearly 40 years I have served as a home care nurse with the Visiting Nurse Service of New York (VNSNY), which was founded by Lillian D. Wald in 1893. We VNSNY nurses collaborate with teammates in other disciplines, such as medicine and social work, to offer home health services—ranging from infant care and acute care to long-term rehabilitation and hospice care—to a highly diverse patient population throughout New York City and two suburban counties.
About a quarter of VNSNY patients are non-English-speaking, including the many Spanish-speaking patients that I care for in the Washington Heights neighborhood of Northern Manhattan. To offer a broader perspective, I am one of about 4,500 Hispanic nurses in a city estimated to have more than 2.5 million Hispanic residents. Working for VNSNY makes me a member of the largest group of Spanish-speaking Hispanic health care providers in our metropolitan area. For the record, VNSNY defines Hispanics as persons who come from Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures. The term “Latino” encompasses people from Brazilian, Asian and African cultures as well.
In 2008, VNSNY was honored with the NAHN New York City Chapter’s first-ever Institutional Award, recognizing our agency for its efforts to “raise awareness of and address health care disparities and increase diversity in nursing” and for being a true champion and outspoken advocate for Hispanic communities in New York City.
Culture and Alzheimer’s
Anderson began his portion of our presentation by noting that the number of U.S. residents aged 65 or older is projected to increase to 12.5 million by 2050, while those aged 85 or older are expected to number 2.6 million at mid century. As the average age rises, the risk of contracting Alzheimer’s disease rises concomitantly. Furthermore, Anderson pointed out, the Alzheimer’s Association reports that the number of Hispanics/Latinos in the U.S. with Alzheimer’s disease and related dementias could increase by more than sixfold by mid century—to as many as 1.3 million.
“The lack of Alzheimer’s resource information in the Spanish language has become a serious barrier to meeting diagnostic and cultural needs and obtaining appropriate services for Hispanic patients suffering from this disease in New York City,” said Anderson, who co-founded the Latino Alzheimer’s Coalition of New York, Inc. (LAC-NY) to address issues related to access, information, advocacy and research.
“Alzheimer’s disease exerts a direct impact on the emotions and behaviors of both diagnosed individuals and their [family] caregivers,” Anderson continued, adding that Alzheimer’s disease is a shared family experience that can have a devastating effect on Hispanic patients’ extended family systems. He noted that studies of Alzheimer’s caregivers have identified increased depression, anxiety, use of psychotropic medications and a negative impact on their work and social lives.
While research is only beginning to uncover the impact of Alzheimer’s disease among Hispanics, the Alzheimer’s Association suggests that this population may be at greater risk for dementia than other ethnic or racial groups, Anderson said. In 2005 the association reported that cardiovascular risk factors such as diabetes and hypertension—which contribute to higher rates of cognitive decline with aging—are also more prevalent among Hispanics.
Patients with Alzheimer’s disease deteriorate and debilitate, requiring supervision and controlled environments to help them remain safe. “Many Hispanic families include working adults who are unable to provide Alzheimer’s patients with the level of care needed in a traditional home setting,” Anderson said. “In spite of their cultural viewpoint that nursing homes are uncaring environments [and that it is the family’s responsibility to care for elders], more Hispanic families find themselves facing the difficult choice of whether to institutionalize their parents in nursing homes.
Therefore, he added, nursing home facilities need to address the needs of Hispanic residents with Alzheimer’s disease and develop a model for providing culturally sensitive living environments and culturally and linguistically competent care. Anderson noted that knowledge and understanding of Hispanic cultural concepts, such as traditional perceptions of illness and intervention, is the key to providing a culturally sensitive approach to care delivery. In addition, health care providers who serve these patients must be trained in cultural nuances, cultural competency, symptom reduction, caregiver receptiveness, engagement in outreach programs and psycho-educational services.
Anderson concluded by presenting a successful best-practice model he developed, which focuses on providing empowerment and improving the quality of life for Hispanic Alzheimer’s patients and their families. His model combines culturally relevant videos and Spanish-language content with a multidisciplinary approach to care delivery that brings together teams of la familia (family), physicians, nurses, social workers, caregivers and informal networks.
As a supplement to this model, Anderson provides cultural competence training to health care providers who serve Hispanic/Latino patients living with Alzheimer’s disease and its clinical co-morbidities, including diabetes. He will soon begin working with the American Diabetes Association as the New York City chair for the ADA’s Por Tu Familia (For your Family) initiative, which will target boroughs with a high percentage of Hispanics/Latinos with diabetes.
The Alzheimer’s/Diabetes Connection
Hispanics also suffer one of the highest rates of diabetes in the United States. In New York City, the prevalence of diabetes among Hispanics is more than 50% higher than average. According to the findings of a recent study conducted by the National Institute on Aging (NIA) under the auspices of the National Institutes of Health’s Intramural Research Program, diabetes can impair a patient’s cognitive health. The study demonstrated that poorly controlled diabetes with high cortisol production causes high levels of stress.
Furthermore, the Alzheimer’s Association has published findings that support the correlation between diabetes, hypertension, obesity and Alzheimer’s disease. When we look at the Hispanic/Latino community, we find a high incidence of these conditions along with high rates of cardiovascular disease. This all contributes to a high risk factor for Alzheimer’s in the Hispanic population.
My portion of our poster presentation was intended to raise awareness of these research findings—and of the importance of controlling diabetes. As a New Yorker whose family emigrated from the mountains of Puerto Rico, I sometimes share with patients that my own mother and father died very young, and that their diet played a role in their heart disease and diabetes.
We VNSNY nurses help diabetes patients with every aspect of managing their disease, so that they can feel better and reduce the risks of long-term health consequences. One patient education tool we have found helpful is our agency’s Diabetes and Meal Planning Guide, which teaches diabetics to incorporate healthy lifestyle modifications, like meal planning and portion control, to help control their blood sugar.
One of my VNSNY colleagues, clinical nurse specialist and diabetes educator Margery Kirsch, MS, RN, CDE, describes the history of our agency’s success in using this tool. “It all started with [the late] Elaine Edelstein, MSN, RN, CDE, who was the VNSNY’s first diabetes clinical nurse specialist,” she explains. “Recognizing the need for a specialized nutrition teaching tool for Spanish-speaking patients in the five boroughs of New York City, in 1996 Elaine developed a guide that showed pictures of correctly portioned, commonly eaten foods, labeling them in both English and Spanish.
“Initially, the tool consisted of food-portion pictures on 4” x 6” laminated cards, attached to a key ring. This format, called Meals on Cards, proved very popular with staff and patients alike,” Margery goes on to say. “Two years later, Elaine expanded the format to a full-size 8 x 11-inch spiral bound book that also included the Food Pyramid and [sample low-calorie meal plans]. This book, which is still one of the most widely used teaching tools at VNSNY, received the prestigious Nutrition Education Award from the American Association of Diabetes Educators. We fondly remember Elaine, who passed away in 2005. Her patient teaching guide makes a fitting memorial to her meaningful work to improve the lives of patients with diabetes.”
Editor’s Note:Anderson Torres, PhD, LCSW-R, director of health initiatives at Bon Secours New York Health System, also contributed to this article.
Among the many electrolytes, potassium stands out. It is perhaps the most prescribed electrolyte, followed by magnesium and phosphorous. In cardiac units, it is one of the staple drugs twinned with digoxin. Brand-name orange juice and milk products are now advertised as “potassium rich” to lure not only consumers concerned with heart health, but also the general public.
The health benefits of potassium
When patients ask why they are given potassium, the standard reply is “it’s good for your heart.” But there is more to it than that. According to the National Council on Potassium in Clinical Practice, evidence supports high-potassium diets can reduce the risk of stroke by combating the effects of sodium.1
When teaching patients about dietary sources of potassium, most nurses stop at bananas. The New England Journal of Medicine published the following categories of excellent potassium sources: Highest Content (>1000 mg [25 mmol] per gram) • Dried figs • Molasses Very High Content (>500 mg [12.5 mmol] per gram) • Dried fruits, nuts • Avocados • Bran cereals, wheat germ • Lima beans High Content (>250 mg [6.2 mmol] per gram) • Vegetables: spinach, tomatoes, broccoli, winter squash, beets, carrots, cauliflower, potatoes • Fruits: bananas, cantaloupe, kiwis, oranges, mangos • Meats: ground beef, steak, pork, veal, lamb
Studies also show reduction in blood pressure after potassium supplementation is three times higher in African Americans than in Caucasians.2 Research suggests that when one’s potassium level is below 3.5 mmol/L, supplementation is essential, even in asymptomatic patients with mild-tomoderate hypertension.3 For patients with a history of arrhythmias, the threshold for potassium replacements is higher: 4.0 mmol/L. The Journal of the American Medical Association reports the risk for ventricular fibrillation in acute myocardial infarction is significantly higher in patients with a potassium deficiency (less than 3.9 mmol/L).
The effect of digoxin is enhanced in the presence of hypokalemia. Hypokalemia predisposes a patient to digoxin toxicity by reducing renal clearance and promoting myocardial binding of the drug.4 Maintaining a normal potassium level is important in preventing digoxin toxicity and minimizing the potential side effects.
The daily minimum requirement for potassium in the average adult is 1600–2000 mg (40–50 mEq). It is interesting to note that across racial lines, it is reported that urban whites consume approximately 2500 mg of potassium per day while African Americans take in only 1000 mg per day on average.5
So what can your patients (and you) eat or drink to get an adequate amount of potassium? For starters, eight ounces of orange juice supplies 450 mg of potassium. Milk and vegetable juice (such as V8) are also rich in potassium but, unfortunately, can be loaded with sodium. Additionally, some of these potassium-rich foods can be costly and potentially cause weight gain. But don’t limit yourself to bananas; seek diverse foods to supplement your potassium intake.
In the hospital setting, compliance with potassium replacements or therapy can be a challenge. Tablets are better tolerated than the liquid form for patients who do not have any difficulty swallowing. Compliance is also enhanced by the dosing schedule; the more infrequently the patient takes the pill, the better the compliance. Instead of giving 20 mEq BID, you can ask the doctor to order it as 40 mEq once a day as clinical condition allows. In patients taking diuretics, dietary consumption of potassium-rich food is not enough and must be coupled with a potassium supplement.
Mixing potassium liquid with juice or ice makes it easier to swallow. To prevent the occlusion of feeding tubes, give the liquid form to the patient instead of crushing the pills. Lastly, it is important to note that magnesium is an essential cofactor for potassium uptake and maintenance of intracellular potassium level.1 Potassium supplementation works best when the magnesium level is within a normal range (1.5–2.5 mEq/L).
Nurses must be particularly keen on improving potassium intake in vulnerable groups such as the elderly, those who live alone, and persons with disabilities or functional limitations—they are most at risk for low potassium intake.
J. Cohn, P. Kowey, P. Whelton, et al., “New guidelines for potassium replacement in clinical practice,” Archive of Internal Medicine 160 (2000): 2429-2436.
P.K. Whelton, J. He, J.A. Cutler, et al., “Effects of oral potassium on blood pressure: meta-analysis of randomized controlled clinical trials,” Journal of the American Medical Association 277 (1997):1624-1632.
P.V. Caralis, B.J. Matterson, E. Perez-Stable, “Potassium and diuretic-induced ventricular arrhythmia in ambulatory hypertensive patients,” Miner Electrolyte Metabolism 10 (1984): 148-154.
A, Bielecka-Dabrowa, D.P. Mikhailidis, L. Jones, et al., “The meaning of hypokalemia in heart failure,” International Journal of Cardiology (2011) doi:10.1016/j.ijcard.2011.06.121
A.K. Mandal, “Hypokalemia and hyperkalemia,” Medical Clinics of North America 81 (1997):611-639.
Because immigrants from Asian countries with large Buddhist populations are a rapidly growing minority group in the U.S., it’s important for nurses to understand Buddhist patients’ beliefs about health, illness and food.
The love of nature and maximum enjoyment of what nature provides us is necessary in order to live a truly natural life. This is the main belief in many Asian cultures, such as those of China, Japan, Taiwan, Korea, Tibet, Sri Lanka, Thailand, India and the Philippines. While Christianity is the dominant religion in many of these countries, there are also significant numbers of Buddhists, along with Muslims, Hindus and atheists.
In the Buddhist faith, life revolves around nature with its two opposing energy systems, known in Chinese philosophy as yin and yang energy. Examples of these opposing energy forces, which are cyclical, include heat/cold, light/darkness, good/evil and sickness/health. Although a simple illness, such as a cold or flu, may be considered an imbalance of yin and yang energy, many Buddhists-though not all-believe that the best way to live a healthy life is to be a vegetarian.
The Buddhist tradition of vegetarianism has gained a great deal of popularity around the globe, as both a diet and a way of life. In the United States alone, there are about 20 million vegetarians. At the same time, in certain Asian cultures there has been a strong movement away from the traditional strict vegetarian diet as a result of these countries’ exposure to Islam and Christianity.
Part of being a culturally competent health care professional is being careful not to make blanket generalizations about patients from unfamiliar cultures-such as assuming that if a patient is an immigrant from an Asian country, he must be a Buddhist. Even if it is known for a fact that the patient’s religion is Buddhism, this does not necessarily mean that he or she strictly follows all Buddhist religious practices to the letter. It is vitally important for nurses to initiate dialogue with patients and their families in order to determine what, if any, cultural/religious needs and dietary restrictions must be accommodated to ensure the best possible healing process for the patient.
Understanding Buddhist Beliefs
The Buddha was born in what is now Nepal and founded Buddhism in India during the sixth century B.C. After Buddha’s death, his followers considered him a divine entity with the ability to lead them to Heaven.
This is a faith of supreme optimism that teaches self-control as a means to search for true happiness. Buddhists practice yoga and meditation as a means to reach spiritual emancipation or true liberation. Through mastering self-control, a Buddhist can reach full potential toward a journey of self-improvement during this life in order to achieve reincarnation, or rebirth after life. The rebirth process requires a desirable state of freedom or purity from primitive human desires and wishes.
The Buddhist code of morality is set forth in the Five Moral Precepts, which are:
1. Do not kill or harm living things.
2. Do not steal.
3. Do not engage in sexual misconduct.
4. Do not lie.
5. Do not consume intoxicants such as alcohol, tobacco or mind-altering drugs.
Buddhists believe that being careful in selecting the food one eats correlates with the amount of light in one’s body and the degree of power necessary to climb up the spiritual ladder-i.e., to reach the desirable state of relaxation and of being sincere to oneself and others. By following this path, one’s soul reaches harmony, the desirable spiritual status and/or the power of virtue necessary to attain the reincarnation process.
Buddhist Dietary Practices
In the teachings of Buddha, this concept of making the right food choices for spiritual enlightenment is exemplified by the “Five Contemplations While Eating.” Essentially, this means that Buddhists are exercising a special force related to “stopping and thinking” about the food they are eating.
(Interestingly, it is believed that the Buddha himself actually died from food poisoning.) A Buddhist asks himself these five basic but essential questions:
1. What food is this? = The origin of the food and how it reached me.
2. Where does it come from? = The amount of work necessary to grow the food, prepare it, cook it and bring it to the table.
3. Why am I eating it? = Do I deserve this food or not? Am I worthy of it?
4. When should I eat and benefit from this food? = Food is a necessity and a healing agent because I am subjected to illness without food.
5. How should I eat it? = Food is only received and eaten for the purpose of realizing the proper way to reach enlightenment.
A Buddhist GlossaryVegetarianism: A diet that includes no meat. In the Buddhist religion, eating a vegetarian diet is a natural and logical ramification of the moral precept against the taking of life. Veganism: A philosophy of life that should be thought of as entirely separate from vegetarianism. It is concerned with an entire lifestyle rather than just a dietary regime. Veganism prohibits not only the eating of animals, animal products and their derivatives-including milk, cheese and honey-but also the use of animal furs, leathers, skins, etc. Vegans believe these products-and even their by-products-must be avoided at both the physical and mental levels to ensure true liberation that facilitates the attaining of enlightenment.Ahimsa: The act of not killing or harming. It refers to the compassionate, non-violent treatment of living things and the acknowledgment of all sentient creatures’ right to live and be reborn. Practicing ahimsa will keep the Buddhist on the right spiritual path and enforces “a better life and better health.”Karma: A sort of spiritual bank account that is accumu-lated through one’s actions in life. Good karma occurs for those who follow Buddhism’s moral precepts; it will lead to being reborn as a higher being, such as a god or wealthy human. Bad karma, which can result from forbidden acts such as killing living things, can cause one to be reborn as a lesser being, such as an animal, insect or demon. Once you pay off your karmic “debts,” you can be reborn as human.
Buddhists who are strict adherents to their faith depend not only on these Five Contemplations but also on the Five Moral Precepts to determine which foods are appropriate to consume and which are considered forbidden. In general, Buddhism prohibits the eating of any and all meat, because (1) the killing of animals violates the First Moral Precept and (2) meat is considered an intoxicant to the body, which violates the Fifth Moral Precept.
According to the Fifth Precept, consuming any type of intoxicants will reflect negatively on a Buddhist’s life and afterlife in the following ways:
o Effects on Self: It will distort and cloud one’s samadhi-i.e, it will hinder one’s judgment and decrease proper concentration necessary for meditation, which is the path to enlightenment.
o Effects on Others: It will increase one’s susceptibility to commit crimes and do wrong to others, which means loss of the desirable self-control.
o Religious/Spiritual Effects: It can cause bad karma (see Glossary) that harms other sentient beings and later on will haunt the original being.
Buddhists believe that whoever lives only for pleasure loses his soul’s harmony and the power of virtue. According to the “no killing” precept, whoever kills animals or eats meat will lose the “purity of both body and mind”-i.e., one gets all mixed up with the meat one eats and loses purity, clarity and the power of self-control. Buddhists also believe that causing the suffering of living creatures just to satisfy our taste buds is not a justifiable reason to eat meat. In Buddhists’ eyes, hunger is the minimal expression of compassion that can be offered and becoming a vegetarian is a choice-i.e., choosing not to kill animals (out of kindness) and not to eat them (out of compassion).
In addition to the physical suffering of animals, Buddhists believe that eating meat also causes another type of suffering: bad karma. Killing a sentient being forces it to begin a painful process of rebirth. Since Buddhists believe it is possible for animals to attain enlightenment, killing them deprives them of that chance. Eating a vegetarian diet helps ensure that the cycle of karmic retribution will be purified:
If you don’t eat animals, they won’t eat you. If you don’t kill them, they won’t kill you.
Other foods that may fall into the “forbidden” category include “the Five Pungent Spices.” This refers to onions, scallions, chives, garlic, etc. Traditionally, Buddhists have believed that a person who eats these foods will suffer the following ill effects:
His blood and flesh will be rejected by the gods, and the heavens will distance themselves far from him.
His breath is always foul; therefore, all gods and saints will reject him.
If eaten cooked, these foods will arouse lust and cause explosive temper.
If eaten raw, they will increase one’s anger and cause bad body odor that will not please the gods but will stimulate interested “hungry ghosts” who will hover around and kiss one’s lips. Being near ghosts is believed to hinder one’s enlightenment.
Today, however, many vegetarians around the world, including some Buddhists, may eat the Five Pungent Spices without reservation. For Buddhists, this depends on such factors as the person’s degree of adherence to their faith, whether they are practicing Buddhism along with other faiths, and their geographic location.
Health Benefits of the Buddhist Diet
Examples of permitted foods that are staples of the traditional Buddhist diet in many Asian cultures include:
1. Boiled or stir-fried noodles flavored with aromatic spices. Raw or cooked vegetables, seaweed and home-prepared dried food items can also be added.
2. Rice, which can be cooked and flavored in many different ways-e.g., salty, sweet, neutral, sticky, colored or mixed with vegetables.
3. Soy sauce is an essential tasty ingredient that is added to almost every dish, in much the same way as Americans flavor many of their foods with butter and/or salt.
4. Sesame oil is also used heavily in preparing food. Unlike soy sauce, it contains no sodium.
5. Buddhists who are not strict vegetarians will eat fish on an almost daily basis and/or will add it to many of their meals.
6. Herbal tea is a popular and healing drink that originates from various types of tea plants.
For centuries Buddhists have believed that when meat is eaten it accumulates in the body, turning into harmful toxins. Today, modern medicine seems to be proving them right. A number of recent scientific studies have discovered a high incidence of cancer within populations that consume large amounts of meat. Other negative health consequences that have been linked with eating meat include arterial sclerosis, heart disease, high blood pressure, encephalitis, stroke, gallstones and cirrhosis of the liver. All of these conditions are directly related to consuming fat and cholesterol.
According to the Encyclopaedia Britannica, meat does in fact contain wastes and toxins, such as uric acid, that have negative effects on blood and body tissues. In contrast, vegetable proteins obtained from nuts, beans and legumes are decidedly healthier and safer. Furthermore, meat, meat products, poultry and seafood all spoil easily within a few hours, but most vegetables stay fresh for several days. Although beans may become rancid relatively quickly, the deterioration is much easier to detect and recognize compared to spoilage in meat, which may not always be detectable by smell or taste.
Cultural Competence Tips for Nurses
When caring for patients who are followers of the Buddhist religion, nurses need to understand that the patient’s main goal is to bring back the body’s yin/yang equilibrium that was disrupted because of illness. It is helpful to first discuss the patient’s illness and care plan in relation to this concept before volunteering a medical or patho-physiological explanation. Because of the supreme importance of nature in Buddhists’ lives, a culturally sensitive medical team will want to prescribe both herbal medicine and pharmaceutical medications, if appropriate. Remember, in these patients’ eyes the goal is not curing but rather maintaining peace of body and mind that will ensure the rebirth process after death.
In terms of dietary assessments, the first step is obviously to find out whether the patient is a vegetarian, how strict or liberal he/she is in following the traditional vegetarian diet and whether there are any other dietary restrictions the patient must observe. The risk of vitamin B12 deficiency among pure vegetarians can be managed by increasing their daily intake of the different types of vegetable proteins.
Buddhist patients staying in a hospital that only serves American-style food may appreciate being provided with a bottle of soy sauce that they can keep in their room to flavor their meals in the way they are accustomed to. The rule of thumb is: When in doubt, ask the patient what he or she would prefer. Be sure to check the labels on different soy sauce products for their sodium content, which can range from 300 grams to as much as 1,080 grams.
Gihan ElGindy, MSN, RN, is an educator and independent consultant on health, nursing, cultural competence, education and business entrepreneurship issues. She is the executive director of the Transcultural Education Center (TEC) in McLean, Virginia. For more information about TEC, visit www.tecenter.org.