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Reaction and Comments on the Nutrition and Dietetics Law of 2016

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Submitted: August 2016

AUTHOR: Luisito O. Llido, MD, FPCS, FPSGS, DPBCN

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(Note: The Nutrition and Dietetics Law of 2016 was passed and signed by President Benigno Aquino III on May 25, 2016. It contained some provisions which encroached on the practice of the medical profession for which this reaction is written. No consultation with the clinical nutrition physicians of the Philippine Society of Parenteral and Enteral Nutrition and Philippine Medical Association was done in the crafting of this law, specially on the area of medical or clinical nutrition therapy)

A position paper on questioned provisions in the Nutrition and Dietetics Law of 2016
Written on behalf of the Philippine Society of Parenteral and Enteral Nutrition (PhilSPEN)

We commend the creation of the Republic Act 10862 otherwise known as the Nutrition and Dietetic Law of 2016. Now the nutrition and dietetics profession has a structured system which encompasses their science and practice and recognized by government.

As we read and reviewed the law, three provisions were noted which raised our concern. These are:

  • Article 6, Section 26 or “Scope of Practice of nutrition and dietetics” [1] – the scope and practice of nutrition and dietetics includes a) providing medical nutrition therapy through the application of the nutrition care process for purposes of disease prevention, treatment and management and b) optimizing the health and well-being of patients/clients through the delivery of quality products, programs and services.
  • Article 6, Section 29 or “Lawful practitioners of nutrition-dietetics” [1] – identifies and claims ONLY the nutritionist-dietitians as the lawful practitioners of nutrition and dietetics
  • Article 8, Section 39 or “Penal Provisions” [1] – imposes penal provisions on any person who commits these acts and are not identified to be within the scope of allowed practitioners of nutrition-dietetics.

In essence these provisions are saying that: medical nutrition therapy which includes the nutrition care process for the purpose of disease prevention, treatment and management is within the scope of practice of the nutritionist and dietitians and it is only the nutritionist and dietitians who are legally allowed to practice this. Those who do not comply i.e. who are not nutritionist and dietitians, will be penalized.

We therefore raise the following issues and positions:

Issue #1: “SCOPE AND PRACTICE OF NUTRITION AND DIETETICS”

Position #1: The practice of nutrition and dietetics is not the “sole province” of the nutritionist-dietitian.

Areas of nutrition and dietetics are also taught and learned in the field of medicine since body composition and function is an integral component of the health and disease state of the patient. When a patient gets sick, understanding the anatomy, physiology, biochemistry and pathophysiology of the human body with all its organ system interrelations are of prime importance in order to deliver an effective treatment to the patient. Nutrition occupies a central point in all these aspects and knowing how to give it makes a difference in the quality care management and outcome of treatment.

This position is implicitly covered in the Medical Act of 1959 where in Article 3 Section 8, it defines the practice of medicine or the practitioner of medicine as one who for compensation, fee, salary or reward in any form paid to him directly or through another, or even without the same, physically examine any person, and diagnose, treat, operate or prescribe any remedy for human disease, injury, deformity, physical, mental, psychical condition or any ailment, real or imaginary, regardless of the nature of the remedy or treatment administered, prescribed or recommended, or who shall by means of signs, cards, advertisements, written or printed matter or through the radio, television or any other means of communication, either offer or undertake by any means or method to diagnose, treat, operate or prescribe any remedy for any human disease, injury, deformity, physical, mental or psychical condition; . [2,3,4,5]

This is further mandated in The Medical Act of 1959, Article 3 Section 21 where these subjects related to nutrition are included in the medical curriculum, which are: anatomy, physiology, biochemistry and nutrition, pharmacology, medicine and therapeutics, pathology and subspecialty subjects like gynecology, ophthalmology, otology, rhinology and laryngology, pediatrics, obstetrics, surgery, preventive medicine and public health. [2,3,4,5]

The traditional hierarchy of hospital care (hierarchy = a system or organization in which people or groups are ranked one above the other according to status or authority) placed on the physician’s shoulders the overall authority to manage the patient. Therefore, this set up:

  • Has the physician prescribing the orders (including food to be given) and the dietitians implementing them. The physician is the “captain of the ship” and bears responsibility for the outcome of treatment, especially during hospital admission.
  • Allowed the hospital diet to be modified by the physician when he/she decides when the patient’s condition requires it;
  • In essence, it is the physician who has the main say regarding “delivery of medical nutrition therapy” especially when the patient is admitted in the hospital – this statement may now be questioned today due to the concept of “multidisciplinary approach to patient care”. [6]

Even ancient history bears this out:

  • Book of Leviticus 11 regarding food allowed and not allowed by God to be eaten. (1447 BC – 1427BC); there was no dietitian then.
  • Hippocrates is quoted to say, “Let food be thy medicine and medicine be thy food.” (460BC - 370BC); there was no dietitian then.
  • The Book of Acts mentions St. Luke was a physician who was giving medical advice to the early Christians (which incudes Timothy); there was no dietitian then.

The concept of multidisciplinary approach to patient care or “team approach”, which in the past three (3) decades has evolved into a component of “best practice” or “evidence based medicine” especially for the hospitalized and home care patient, has also put this claim into question since it is now accepted that no one has full grasp of all the expertise required to deliver optimum patient care. These are the developments behind this change:

  • The nutrition care process is designed for a multidisciplinary approach to nutrition management: nutrition screening and assessment is the responsibility of all members of the team, the physician and dietitian are both involved in nutrition care plan and implementation (which includes the nurse and pharmacist) and the rest are again involved in monitoring and reassessment of the nutrition care process. [6] These interactivity is fully seen and felt in hospital based and home-care based nutrition.
  • It is in this context that the ASPEN (American Society of Parenteral and Enteral Nutrition), ESPEN (European Society of Parneteral and Enteral Nutrition), FELANPE (Latin American Society of Parenteral and Enteral Nutrition), PENSA (Parenteral and Enteral Nutrition Society of Asia) and lately PhilSPEN (Philippine Society of Parenteral and Enteral Nutrition, founded in 1994) came to be with two goals in mind: improve nutrition care through a team approach and research and to establish protocols and guidelines for “best practice” outcomes. [7]
  • As a consequence of these developments PhilSPEN organized the training of physicians in the science and practice of nutrition care (hospital and home care based) under the umbrella term “Clinical Nutrition Practice” subspecialty and training (Clinical Nutrition Fellowship Training Program based in St. Luke’s Medical Center – Quezon City). [8] This is a two (2) year program which started in 2000 and regulated by the Philippine Board of Clinical Nutrition (PBCN organized in 2007). [7,8,9] It was originally designed for the team, but talks with the other governing bodies did not push through so only the physician component was retained. [10] Here clinical nutrition covers medical, surgical, geriatric, pediatric nutrition therapy and more.
  • It is also in this context that the Master of Science in Clinical Nutrition (launched in 2004 in PWU) was developed to help in improving hospital based and home care based practice in the country through development of the nutrition team components (e.g. physician, dietitian, nurse and pharmacist). [7]
  • The need for improvement of the learning and practice of medical nutrition therapy is raised in the Nutrition and Dietetics Law of 2016, Section 36 – Integration of the nutrition and dietetics profession. The need to update the education and quality of nutrition practice of their peers is recognized and they don’t have to look far – the answer is just around the corner: the MSCN of PWU (Master of Science in Clinical Nutrition of the Philippine Women's University) and the Clinical Nutrition Fellowship Training Program of SLMC-QC (St. Luke's Medical Center - Quezon city). [7,9] These two and specifically PhilSPEN have been helping out through conferences, convention and training (short term and long term) for the past twelve to fifteen (12 - 15) years. [7,9]

Position #2: This contention is also raised in the area of the nutritionist-dietitian’s delivery of the “nutrition care process” for disease prevention, treatment and management.

  • In the context of the delivery of nutrition care through a multidisciplinary approach, the physician is designated the team leader and overall command of the nutrition care process; again he bears the overall responsibility of the outcome of patient care, be it hospital or home care based. [6]
  • The role of the dietitian is to make suggestions to the planned management and once agreed by the team, to implement nutrition therapy, which in most instances is enteral nutrition therapy; parenteral nutrition is placed mainly in the responsibility of the physician, pharmacist and nurse.
  • This statement involves two health care givers: the physician who treats and manages the disease and the dietitian who delivers the nutrition. The nutrition care process requires the nutrition care plan which is mainly done by the physician with the help of the dietitian and the nutrition care implementation which involves the role primarily of the dietitian, nurse and pharmacist. Monitoring also involves the members of the team.
  • Clearly disease prevention, treatment and management is a team/multidisciplinary process.

In conclusion, as far as issue #1 is concerned, based on the aforementioned points, medical nutrition therapy is also a part of the physician’s major tool in patient care since understanding the disease process, how the body responds to it and providing the appropriate nutrition and other therapeutic regimens comprise are essential components of patient care. It is not a “sole province” of the nutritionist-dietitian

Issue #2: THE LAWFUL PRACTICE OF NUTRITION AND DIETETICS SOLELY ATTRIBUTED TO THE NUTRITIONIST-DIETITIAN AND THOSE WHO DISOBEY ARE PENALIZED

For the delivery of an optimum, unified, safe and comprehensive medical care the practice has to be standardized based on credentialing, protocols and guidelines. This requires that assigned personnel or caregivers are credentialed to have adequate training and passed the minimum requirements of practice based on the state/county or professional board accreditors. It needs the presence of a law to “put teeth” in its implementation.

Claiming that it is only the nutritionist-dietitian who is lawfully allowed to deliver medical nutrition therapy may be a bit “narrow minded”, restrictive and dangerous especially for the hospitalized patient. I feel that with this move we have shifted from the "golden age" back into the “dark ages” of clinical nutrition practice.

Position #3: The over-all care of the patient has been placed primarily on the shoulders of the physician and this includes medical nutrition therapy (or clinical nutrition management) especially for the hospitalized or home care patient. Making or treating this component of patient care as “illegal” on the part of the physician is essentially removing a key component of the patient care process from the medical profession and placing this responsibility on the shoulders of the nutritionist and dietitian, who are not trained in the science and art of patient medical or surgical treatment in all its aspects.

This move has gone against the intentions of giving the best care to the patient through hampering the physician’s capacity to deliver full care to the patient, dismantling the process of best practice by declaring the multidisciplinary approach to nutrition care illegal and assuming responsibilities in patient care that they are not trained for or having experience with.

More questions that ask for clarification and last comment:

  • By history and since the passing of the Medical Act of 1959, nutrition and dietetics (although not technically named as such) has been part of the physician’s practice – why this recent, sudden declaration of the nutritionist-dietitians' rights?
  • Today we even have physicians who are trained and practice clinical nutrition therapy (hospital or home care based) which includes medical nutrition therapy in answer to the concern that physicians need to update their knowledge and practice of nutrition for their patients. (7,8,10) Is the entry of these new breed of physician subspecialists posing a threat to the nutritionist-dietitian profession? If we have given this impression, then we are sorry, this has never been our intention.
  • We understand the Nutrition and Dietetics Law of 2016 is designed for the dietitians and nutritionists, but when this intrudes into the practice of the medical profession, then it is raising a red flag – when a new law infringes on another law in some or all of its intents and purposes this situation puts that new law into question.
  • We may be somewhat amenable to Section 26a, but Section 29 needs a “redo”.

REFERENCES:

  • Republic Act 10862 otherwise known as “Nutrition and Dietetics Law of 2016” was signed into law by President Benigno Aquino III on May 25, 2016.
  • Republic Act No. 2382 – “The Medical Act of 1959”
  • Republic Act No. 4224 - “An Act to amend certain sections of Republic Act Number Twenty-Three Hundred and Eighty-Two, otherwise known as "The Medical Act of 1959."
  • Republic Act No. 5946 – “An Act to amend certain sections of Republic Act Number Twenty-Three Hundred and Eighty-Two, otherwise known as "The Medical Act of 1959" as amended by Republic Act Number Forty-Two Hundred and Twenty Four“
  • Physicians’ Act of 2013 – senate version by Senator Jinggoy Estrada
  • ASPEN Core Curriculum of 1994.
  • http://www.dpsys120991.com. First official website of the Philippine Society of Parenteral and Enteral Nutrition. Accessed August 8, 2016.
  • http://www.philspenonlinejournal.com/philspen_constitution.php. Constitution and By-Laws of PBCN: What is clinical nutrition practice? Accessed August 9, 2016.
  • https://philspen.wildapricot.org. Second official website of the Philippine Society of Parenteral and Enteral Nutrition. Accessed August 8, 2016
  • http://www.philspenonlinejournal.com/pbcn_board_resolutions.php#boardres_02  Accessed August 9, 2016.

 

Prepared and submitted on behalf of the Philippine Society of Parenteral and Enteral Nutrition.
ndlaw20162
Dr. Luisito Llido
Board Member
Philippine Society of Parenteral and Enteral Nutrition (PhilSPEN)
August 11, 2016

 

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