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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:

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:

Even ancient history bears this out:

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:

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 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:

REFERENCES:1.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.

 

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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