1. Southeast Asians and Pacific Islanders Chapter 12

2. Introduction Tropical regions Markedly different cultures Chinese Spanish in the Philippines French in Vietnam Newest, youngest, fastest growing population in the US

3. Includes SE Asians ◦ Filipinos ◦ Vietnamese ◦ Cambodians ◦ Laotians Pacific Islanders ◦ Native Hawaiians ◦ Samoans ◦ Guamanians ◦ Tongans

4. History of SE Asians in the US: Immigration Filipinos immigrate to the US for educational and economic opportunities SE Asians have come to the US since the 1970s as refugees Phillipines immigration increased after 1898 when it became a US territory ◦ Young men came to Hawaii to work in the sugar cane fields ◦ US nationals Very slow from 1924 - 1965

5. History of SE Asians in the US Filipinos could become US citizens after WWII Many came to the US after 1965 as professional or technical workers Vietnamese immigration in the 1970s due to political and economic reasons 3 distinct waves When South Vietnam fell to the North in 1975 1975-77 – left for political/economic reasons 1978 – Ethnic Chinese fled because of China invading North Vietnam

6. History of SE Asians in the US Cambodian and Laotians occurred from 1976 – 1979 when the US granted asylum to refugees Many were of tribal populations from the mountains  The Hmong and Mien (ethnic Chinese) Many refugees in numerous refugee camps were of concern

7. Current Demographics and Socioeconomic Status: Filipinos Population more than doubled since 1980 Half live in California Heterogeneous group Citizenship rates higher than other Asian groups Educational attainment is high Family median incomes above national average Poverty rates half that of the general US population

8. Current Demographics and Socioeconomic Status: Vietnamese Population has more than doubled since 1990 Relocated to western and Gulf states First wave were well educated and spoke English Second group not as prepared Assimilated quickly Education highly valued High rates of employment Median family income lower than US average Poverty rates higher than US average English may not be spoken at home

9. Current Demographics and Socioeconomic Status: Cambodian Over 90% have arrived since 1990 Half in California Adjustment difficult Came from rural regions where they were farmers High unemployment rate Income below national average 30% below poverty level Low levels of educational attainment ◦ More than half do not have a HS education

10. Current Demographics and Socioeconomic Status: Laotians 3 groups ◦ Non-tribal Laotians in CA, TX, MN, WA ◦ Hmong in MN and CA ◦ Mien in CA, OR, WA, AK Poor fluency in English Low education levels ◦ Over 60% have not completed HS Laotians have low rates of poverty Hmong have lowest median family income of all immigrants ◦ Poverty rates 3x the national average

11. Worldview: Religion SE Asians often believe in spirits and ghosts, especially of ancestors ◦ Guard against misfortune ◦ Cause harm and suffering Filipinos are primarily Roman Catholic ◦ Accept one’s fate as supernatural forces control the world ◦ Time and providence will solve all problems

12. Worldview: Religion Vietnamese ◦ 70% Buddhists ◦ 30% Roman Catholic ◦ Consider themselves part of a greater force in the universe Cambodian ◦ Theraveda Buddhism ◦ Great emphasis on reaching spiritual perfection

13. Worldview: Religion Laotian ◦ Theraveda Buddhists ◦ Must devote some time being a monk ◦ Hmong  About half are Christian  May still practice ancestor worship  Other half practice animism, shamanism and ancestor worship  Two spheres of the world – the visible and invisible

14. Worldview: Family Interpersonal relationship are emphasized SE Asians share common values ◦ High esteem for family ◦ Respect for elders ◦ Interdependence among family members ◦ Behavior that would bring shame avoided ◦ Avoid direct expression of conflict ◦ Social acceptance and smooth

15. Worldview: Family Filipino family highly structured Extended family at the center with kinship extended to neighbors, etc. Patriarchal Children indulged until age 6 Women may not be encouraged to attend school as beyond family supervision

16. Worldview: Family Vietnamese family in US adapted to American norms Larger than typical US family Family will live nearby Family values are in transition Father has been head of household, now becoming les prevalent American-style dating common Divorce uncommon High levels of intergenerational conflict Old age not as valued as it had been before

17. Worldview: Family Cambodian families are large and extended Children are treasures Men provide for families, women take care of the budget Has been difficult to maintain traditional family structure due to many female-headed households ◦ Men killed in conflicts in Cambodia Cambodian women can have formal education Differences in the US can be very great

18. Worldview: Family Laotians an agriculturally based family in Laos Men represented the family Women ran the home Great significance is given to the site of the family’s home Extended families still important, but nuclear families the norm in the US Women have nearly equal status to men in the US Low divorce rate

19. Worldview: Family Hmong American families are the youngest and largest in the US Nuclear families of about 6 members Extended family often live nearby Men heads of household but women held in high regard Men assume a larger role in childcare in the US Children are the heart of the home ◦ At age 5 are expected to act as adults

20. Worldview: Family Teenage runaways common among the Hmong Some Hmong customs in direct conflict with US laws ◦ Polygamy ◦ Kidnapping of young women and forced marriage Conversion to Christianity has split many families Much conflict over marriage traditions

21. Traditional Health Beliefs and Practices In SE Asia origins of illness focus on supernatural world ◦ Intervention of malevolent spirits ◦ Ghosts of angry ancestors Chinese medical practices often used Mexican hot/cold theory more prevalent in the Philippines Health requires personal harmony and fulfilling obligations Illness is defined by cause, not symptoms

22. Traditional Health Beliefs and Practices: Filipinos Adhere to the concept of bahala na ◦ Life is controlled by the will of God and by supernatural forces ◦ Rewarded with health in this life and eternal life after death ◦ Illness a punishment for transgressions against God ◦ Religious medals worn for protection from evil

23. Traditional Health Beliefs and Practices: Filipinos Supernatural illness due to unhappy ghosts of ancestors Witchcraft or animal spirits may be involved Evil eye (usog) common Undesirable traits or conditions can be transferred magically through contact with person or object ◦ Pregnant women will try to look on beautiful objects Forces do not apply in the US as spirits and ghosts cannot cross the ocean or survive in noisy cities

24. Traditional Health Beliefs and Practices: Filipinos 3 practices produce balance (timbering) ◦ Heating  Warm body prevents illness  Exposure to elements OR hot/cold foods  Imbalance causes illness ◦ Protection  Layer of fat needed to protect body from cooling  Wind of great concern  Through pores or any wounds or drafts ◦ Flushing  Cleanse from impurities or evil forces  Perspiration, flatulence, vomiting, or menstrual blood

25. Traditional Health Beliefs and Practices: Filipinos Traditional healers ◦ Midwives ◦ Masseurs ◦ Curers  Evaluate pulse and diagnose ◦ Arbularyos  Herbalists ◦ Shamans ◦ Faith healers  Gaining in popularity

26. Traditional Health Beliefs and Practices: Vietnamese Health related to personal destiny ◦ How one behaved in past lives, number of good deeds performed by one’s ancestors determine experiences in this life ◦ Also Current behavior Pregnant women avoid funerals, ugly objects, leaving home between noon and 5 pm when malevolent spirits walk Use divination to predict how a person might expect his life to proceed

27. Traditional Health Beliefs and Practices: Vietnamese Believe there are 3 separate souls ◦ One encompasses the life force ◦ One represents intelligence ◦ One embodies emotions 9 vital spirits provide assistance to the souls Soul loss can cause illness and death Strong feelings, especially fright, can cause the soul to leave the body

28. Traditional Health Beliefs and Practices Chinese medical system used by ethnic Chinese ◦ Some Vietnamese Balance yin/yang ◦ Diet ◦ Treatment of disease ◦ Filipinos may do this Filipinos and Hmong will be concerned with wind or air

29. Traditional Health Beliefs and Practices: Cambodian, Laotian, Hmong Spiritual intervention Laotians identify 32 spirits who oversee the 32 body organs Laotian baci rituals to bind soul to body Hmong recognize the world of the invisible ◦ Ancestor spirits especially important ◦ Soul loss very important cause of illness ◦ Ceeb is “fright illness”  Typically in children  From accidents, chased by a dog, startled by a noise, plunged into cold water

30. Traditional Health Beliefs and Practices Sudden Unexpected Nocturnal Death Syndrome (SUNDS) When a healthy person dies in their sleep Prevalent among Cambodians, Laotians, Hmong Was leading cause of death among Hmong men ages 25 – 40 Nightmare spirit dab tsog enters room at night and crushes the victim by sitting on their chest

31. Traditional Health Beliefs and Practices Hmong traditional healers Hmong herbalists ◦ Treat natural disorders ◦ Use teas and poultices Hmong shamans ◦ Treat spiritual disorders May be treated by anyone with healing experience ◦ Always in the home first

32. Traditional Health Beliefs and Practices Botanical remedies popular Herb gardens maintained Prepared as teas, broths, steam inhalants, balms Physical therapies include massage, cupping, moxibustion, coining, scratching or pinching therapies ◦ Releases bad wind or excess heat and restores balance

33. Traditional Health Beliefs and Practices Religious rituals also intervene on behalf of ill person Hmong soul callers ◦ “Mandate of Life” ceremony ◦ Return a lost soul Mien appeal to ancestor spirits May include animal offerings ◦ Its soul offered in exchange for the victim’s missing soul

34. Traditional Health Beliefs and Practices In Vietnam small shrines constructed to appease ancestor spirits or souls of premature infants who have died Catholic Filipino & Vietnamese appeal to Virgin Mary Christian Hmong may avoid use of traditional practitioners ◦ May still use herbals

35. TRADITIONAL FOOD HABITS: INGREDIENTS AND COMMON FOODS

36. Staples and Regional Variations: Filipino Blended cuisine ◦ Malaysian ◦ Polynesian ◦ Spanish ◦ Chinese Ingredients similar Food prep methods, meal patterns reflect foreign culture ◦ Vietnamese – French ◦ Filipino – Spain Use strongly flavored fish sauces and pastes

37. Three principles of Filipino cooking Never cook any food by itself Fry with garlic in olive oil or lard Foods should have a sour-cool-salty taste ◦ Ex: Adobo combines marinated chicken, pork, fish/shellfish fried in garlic in lard, braised in soy sauce, vinegar, garlic, chili peppers, bay leaf, and peppercorn with plantains, potatoes, greens or bamboo shoots Clay pots are traditional but woks are used now

38. Staples and Regional Variations: Filipino Rice foundation of diet ◦ Steamed or fried ◦ Pan de sal from rice flour Amount of meat depends on economic status ◦ Pork, chicken, fish ◦ Lumpia  Filipino egg rolls ◦ Chicken relleno  Whole stuffed chicken Use all parts of the animal Balut - partially developed duck soft-boiled and served warm by street vendors

39. Staples and Regional Variations: Filipino Dairy products available ◦ Cow’s milk used infrequently Evaporated milk commonly used Water buffalo (carabao) milk used ◦ Used to make cheese called Kesong puti ◦ Popular in desserts like ice cream, flan Fermented fish paste used as seasoning Sour ingredients marinate and pickle raw foods including fruits and vegetables

40. Staples and Regional Variations: Filipino Coconut is a principle food in many Pacific Islands ◦ Dried kernels for oil extraction ◦ Export ◦ Beverages  Coconut juice or water ◦ Cooking liquids  Coconut cream and milk ◦ Vegetables  Hearts of palm or palmetto cabbage ◦ Alcoholic beverages  Coconut palm blossom sap fermented to produce tuba, distilled to form lambanog

41. Staples and Regional Variations: Filipino Fruits consumed include ◦ Bananas ◦ Durian  Strong odor ◦ Jackfruit ◦ Mango ◦ Papaya ◦ Pineapples

42. Staples and Regional Variations: Filipino Divided into four regions ◦ Luzon  Home of Manila, the capital  Various ethnic groups  Strong Spanish influence  Fish in the north  Boiled or steamed foods  Rice grown here  Stir-frying is common  Coconuts and tropical fruits

43. Staples and Regional Variations: Filipino Bicolandia ◦ Ethnically homogeneous ◦ Malaysian and Polynesian influence ◦ Spicy hot with chile peppers Viscayan Islands ◦ Seafood ◦ Dessert specialties due to sugarcane plantations Mindanao ◦ Heavy influence from Indonesia and Malaysia ◦ Heavily Muslim so little pork consumed ◦ Sauces from peanuts, chiles, curries, spicy dishes

44. Staples and Regional Variations: Vietnamese, Cambodian, and Laotian Indigenous fish and seafood, tropical fruits and vegetables and glutinous rice are foundation of the diet Chinese and French influence ◦ French bread a staple Malaysian and Indian influence as well ◦ Curries, coconut milk dishes

45. Staples and Regional Variations: Vietnamese, Cambodian, and Laotian Short- and long-grain rice ◦ Noodles, paper, flour ◦ Paper used for egg rolls or wonton wrappers Fried noodles Fish and shellfish main protein food Poultry, pork or goat in wealthier areas ◦ Religious dietary restrictions may be an issue Few dairy products ◦ Soy milk and tempeh Fermented fish paste used to season

46. Staples and Regional Variations: Vietnamese, Cambodian, and Laotian Vegetables consumed frequently ◦ Stir-fried, stews, uncooked, pickles ◦ Leaves may be used to wrap foods ◦ Fresh herbs and spices  Spicy ground meat or fish ◦ French influence brought asparagus, green beans, potatoes Many tropical fruits

47. Staples and Regional Variations: Vietnamese, Cambodian, and Laotian Tea is the preferred beverage ◦ Before and after, not during ◦ Blended with flowers Coffee popular in French-influenced areas Broth ◦ Only beverage besides water available for most Hmong Beer and soft drinks in wealthier areas Soybean and fruit drinks common Rice wine or whiskey at special occasions

48. Staples and Regional Variations: Vietnamese Chinese influence in the north of Vietnam is strong ◦ Hot pots, stir-fried, soup ◦ Presentation emphasized ◦ Seasonal cooking South is tropical ◦ Simpler cooking, stronger seasoning ◦ Curries, peanut sauces ◦ Coconut, caramel ◦ Clay pot cooking

49. Staples and Regional Variations: Cambodian Khmer cooking of Cambodia ◦ Elements of northern Indian, Malaysian, Chinese ◦ Aromatic seasonings ◦ Spice like chile peppers with coconut milk ◦ Sweet –sour, salty-bitter ◦ Kroeung is a paste that is made fresh for each dish with ◦ different spices and herbs ◦ Amok – fish coconut milk steamed in a banana leaf

50. Staples and Regional Variations: Laotian Prefer glutinous rice Added vegetables and fish make up bulk of diet Eggs, poultry, beef as affordable Game meat, grasshoppers, snakes Meats usually grilled or stewed Salty beef jerky prepared with nam pa ◦ A national specialty Spicy salads Chinese and Vietnamese influences seen

51. Staples and Regional Variations: Hmong Hmong shares some similarities with Vietnamese Long-grain rice and vegetables are base of diet ◦ Stir-frying, steaming, and roasting are common preparation methods May raise chickens, duck, pigeons, pigs ◦ Supplement with game, fish, snails Use soy sauce and fish sauces

52. Meal Composition and Cycle: Daily Pattern - Filipino 3 meals a day Breakfast is garlic fried rice with eggs or broiled fish, coffee or hot chocolate ◦ Ensaymadas are cheesy, sweet rolls Lunch and dinner similar and usually large ◦ Soup, rice, crispy or chewy dish, salty dish, sour dish, noodle dish and often an adobo dish with fresh fruit for dessert ◦ Served in courses if Spanish-style, all together if Filipino-style Snacks midmorning and late afternoon ◦ Never eat rice as a snack as it is reserved for meals only

53. Meal Composition and Cycle: Daily Pattern – Vietnamese and Others 2 or 3 meals daily with number and amount of meals dependent on income Snacking uncommon Do not associate particular foods with specific meals Soups consumed at every meal Large breakfasts Always includes rice All items served at once and consumed family style

54. Meal Composition and Cycle: Daily Pattern – Cambodian Family style Soups at every meal Lunch and dinner with rice or rice noodles with grilled or steamed fish and seafood, salad with fruit as dessert Tea, coffee, condensed meal ◦ Maybe fruit juices, soft drinks, beer, rice wine, whiskey Chile pepper paste is standard condiment

55. Etiquette Use lazy Susan turntables No one starts eating until the eldest male begins May use forks, knives, spoons, or no knives ◦ Chopsticks or fingers may be used ◦ Right hand used for dining with fingers Don’t take last food from plate

56. Etiquette In Vietnam, low table with family sitting cross-legged on mats Hands on table Limited conversation In Laos, there is lots of conversation Food served on rattan tray Men on one side, women on the other Each diner eats from the dishes as desired

57. Etiquette: Utensils Chopsticks used for most dishes in most of Vietnam Spoons /fingers appropriate for certain foods in some areas Rural Laotians may use their fingers, using balls of sticky rice to scoop up fish/meats/vegetables/sauce Spoons are used as needed In urban areas forks are now common Hmong typically use forks and spoons Cambodians use spoons, chopsticks, or fingers

58. Special Occasions - Filipino Predominantly Catholic festivals Food served buffet-style with a roasted pig (lechon) as the centerpiece Media noche after midnight mass on Christmas Eve and New Year’s Eve with fiesta foods Many practices with Easter

59. Special Occasions: Vietnamese New Year’s Celebration called Tet ◦ Observance at family grave sites 23rd day of the 12th lunar month ◦ Celebrates departure of the Spirit of the Heart, Ong Tao  Returns to celestial realm each year to report on family behavior  Returns one week later Buddhist holiday called Trung Nguyen or Wandering Souls Day for Vietnamese Birthdays not traditionally celebrated but death dates

60. Special Occasions: Other Mainland SE Asians Cambodia’s largest holiday is also New Year’s Chaul Chnam ◦ Prayers and special foods offered to New Year’s Angel Water Festival in November Laotian holidays religious in origin ◦ Pha Vet commemorates the life of Buddha ◦ Boon Bang Fay honors Buddha with fireworks Hmong and Laotians’ biggest celebration is New Year’s

61. Therapeutic Uses of Food - Filipino Philippines introduced to hot/cold theory from Spanish ◦ By innate qualities or effect on body ◦ Not by spiciness or temperature Balance attempted at meals

62. Therapeutic Uses of Food - Filipino Hot Foods ◦ Avocados ◦ Alcohol ◦ Coconuts ◦ Nuts ◦ Legumes ◦ Spices ◦ Chile peppers ◦ Fatty meats Cold Foods ◦ Tropical fruits ◦ Vegetables ◦ Milk and dairy ◦ Eggs ◦ Fish ◦ Lean or inexpensive meats

63. Therapeutic Uses of Food - Filipino Hot or cold illnesses ◦ Diarrhea and fevers are hot ◦ Colds and chills are cold Sympathetic qualities ◦ Like causes like

64. Therapeutic Uses of Food - Filipino Herbals popular and may be approved by their Dept of Health ◦ Bitter melon for diabetes ◦ Garlic to lower cholesterol and BP ◦ Pepperonia to treat arthritis and gout ◦ Sambong as a diuretic Betel nuts to prevent tooth decay ◦ Leave permanent stains

65. Therapeutic Uses of Food: Vietnamese and Other Mainland Asians Vietnamese follow yin (âm) - yang (duong) theory from Chinese Classification based on characteristics rather than temperature or spiciness Balance must be maintained within a meal but also avoid extremes during certain conditions like pregnancy

66. Therapeutic Uses of Food: Vietnamese and Other Mainland Asians Hot Foods Red meat Unripe fruit Ginger Garlic Coffee Alcohol Cold Foods Noodles Bananas Oranges Gelatin Ice cream

67. Therapeutic Uses of Food: Vietnamese and Other Mainland Asians Five flavors of sour, bitter, sweet, pungent, salty Specific organ meats will benefit internal organs ◦ Eat liver for a stronger liver May avoid some foods because they resemble disorders ◦ Pregnant women may refuse to eat ginger because it is multi-lobed and believed to cause too many digits in the baby

68. Therapeutic Uses of Food: Vietnamese and Other Mainland Asians Chile peppers to get rid of worms Noodles with roasted rice paper and shrimp sauce for curing the flu Cambodians may drink water with bitter melon for fevers Vietnamese pregnant women may consume large amounts of salt Mothers may not feed babies chicken or duck to prevent children from becoming deaf or mute

69. Contemporary Food Habits in the US: Adaptations of Food Habits: Filipinos Can obtain traditional foods easily May eat rice daily, but not with every meal Have more variety in the US ◦ More milk, green vegetables, meat, sweets All maintain some traditional foods Snacking uncommon Filipinos born in the US eat traditional US breakfast ◦ Traditional items appear periodically

70. Contemporary Food Habits in the US: Vietnamese and Other SE Asians Eat more bread in the US Still eat rice daily More meat and poultry, less fish and shellfish Pork preferred to beef Vietnamese- American adolescents prefer native diet

71. Contemporary Food Habits in the US: Adaptations of Food Habits Similar findings with the Hmong and Cambodians Most-liked items among the adults ◦ Steak, oranges, candy, and soft drinks ◦ All of which are prestige foods in Cambodia and Laos Least-liked items ◦ Cheese, chocolate milk, and milk. May eat just 2 meals daily ◦ Children will have free lunch Grow their own fruits and vegetables, seasonings Some harvest fish ◦ Many will consume the whole fish

72. Contemporary Food Habits in the US: Adaptations of Food Habits Women report more help with shopping or cooking from the men Adolescents may help with food purchases and fixing dinner Women more likely to have a job or be in school Eat fewer meals together

73. Nutritional Status: Intake - Filipinos Traditional diet higher in total fat, saturated fat and cholesterol than other Asian diets Have high cholesterol levels and high rates of hypertension May have genetic inability to process large amounts of sodium in diet Low rates of alcohol consumption ◦ Will increase their blood pressure Life expectancy rates higher Heart disease leading cause of death

74. Nutritional Status: Intake - Filipinos Cancer risk is low Exceptions: lip, oral cavity, pharynx, liver, and thyroid are above the national average Infant mortality slightly below average High rates of preeclampsia, gestational diabetes, LBW, preterm delivery compared to other Asians ◦ Neonates at greater risk for death from infection ◦ Post neonates from respiratory distress syndrome

75. Nutritional Status: Intake - Filipinos Rates of overweight and obesity higher than in other Asian groups Lower than the general population Type 2 diabetes rates 2 – 3x US average ◦ Women have larger waist circumference ◦ Greater risk of gestational diabetes Rates for hyperuricemia (resulting in gouty arthritis) higher ◦ Diet may also be higher in purines, which they should avoid with gout

76. Nutritional Status: Intake - Filipinos Many are lactose intolerant Calcium intake may be limited ◦ Sources are dried fish, fish sauce and paste May have poor intake of vitamin A Stained teeth from chewing betel nuts

77. Nutritional Status: Intake: Vietnamese Calcium intake may be low ◦ Broth from acidified bones analyzed and found that 1 T provided nearly as much calcium as ½ cup of milk Riboflavin, magnesium, zinc consumption low Deficiencies in pregnancy numerous Iron intake marginal ◦ Anemia rates in refugees vary from 6 – 37%

78. Nutritional Status: Intake – Vietnamese Health conditions among immigrants compromise nutrition ◦ TB  50 – 60% of immigrants test positive ◦ Intestinal parasites ◦ Malaria ◦ Liver and renal disease  Hepatitis is prevalent ◦ Dental problems from chronic malnutrition  Or in the US from too many sweets Thallasemia Poor compliance with treatment

79. Nutritional Status: Intake – Vietnamese Life expectancy higher for Vietnamese Americans than for general population Leading cause of death is heart disease ◦ Cervical cancer high in women Obesity rates very low but risk increases with length of stay in the US ◦ Lowest of all Asians ◦ Essential hypertension and insulin resistance more likely with higher BMI Waist-to-hip ratios higher

80. Nutritional Status: Intake: Other SE Asians Scant data on Cambodian and Laotian Americans Diabetes mortality rate for Cambodians and Laotians much higher Stroke deaths more than double the average for both ◦ May also include Hmong and Mien Hmong rates of obesity, diabetes, hypertension, CVD, kidney failure, cancers all increasing ◦ Low adherence to treatment ◦ May choose no treatment ◦ Mortality rates in women 3 – 4 x higher in Hmong women than other groups

81. Nutritional Status: Intake: Other Mainland SE Asians Recent immigrants have high incidence of LBW from poor maternal weight gain ◦ Gain less weight to have smaller babies and easier birth Infant mortality rates are low for SE Asians ◦ Still with nutritional deficiencies ◦ Inadequate prenatal care ◦ Low social economic status Hmong and Laotian infant mortality rates increased

82. Nutritional Status: Intake – Vietnamese & Other Mainland SE Asians Most babies in SE Asia breast-fed for 1 year In the US declines drastically ◦ Believe formula nutritionally superior Introduce solid foods later Overweight may be associated with health and babies may be overfed Babies are 1 year old at birth from lunar calendar

83. Counseling: Filipinos Accept illness as fate Tolerate symptoms until forced to seek care May consult family, healers before biomedical care obtained Language barriers may be significant High context Expression formal and polite Avoid confrontation

84. Counseling: Filipinos Do not address elders by first names Avoid situations where self-esteem may be lost Modesty may make some topics difficult ◦ Sexuality ◦ TB ◦ Mental illness

85. Counseling: Filipinos Handshaking is common greeting Avoid other touching Keep hands at sides, not in pockets Direct eye contact not common May expect quick results from health providers Traditional healers may be used Relatives play significant role in treatment and recovery ◦ Discuss plans with family members as well as patients Compliance may be motivated to fulfill familial obligations

86. Counseling: Filipino Limited access to health care and lack of insurance Language barriers Illness in the hands of God, spirits or fate May deny symptoms intolerable or home remedies ineffective Prevention not common Compliance motivated by desire to fulfill familial obligations and participate in social life Use in depth interview

87. Counseling: Vietnamese & Other SE Asians Limited access to health care and insurance Trust very important ◦ May be suspicious of biomedical care Fear invasive tests due to upsetting body balance Avoid surgery and autopsies due to fear of relationship between body and soul Privacy issues of concern Same sex health care provider

88. Counseling: Vietnamese & Other SE Asians Want full description of disorders and therapies Health care decision may be the responsibility of the elders or the entire family Histories may be difficult to obtain because they have not known the name of their conditions Polite, unhurried, reserved conversational style appreciated Avoid negative statements and outcomes with Hmong

89. Counseling: Vietnamese & Other SE Asians Confucian and Buddhist beliefs encourage modesty Head is sacred Don’t show the bottom of the foot or shoes and don’t point with foot Don’t snap fingers or signal with upturned index fingers Show respect by bowing head and using both hands to present an item to elders

90. Counseling: Vietnamese & Other SE Asians Refugees from mainland SE Asia at risk for mental health problems ◦ PTSD Adherence to traditional health beliefs varies ◦ Christian churches discourage ancestor worship Many continue with coining and home remedies Hot/cold theories Herbal remedies Consult healers and biomedicine

91. Counseling: Vietnamese & Other SE Asians Vietnamese see biomedicine as yang (hot) and traditional medicine as yin (cold) ◦ Biomedicine fast-acting, temporary, with side effects ◦ Traditional seen as slow-acting, gentle, without side effects, permanent and preventive ◦ Will use both yin and yang In depth interview a must

92. Counseling: Vietnamese & Other SE Asians Herbal remedies ◦ Slang nut is source of strychnine and poisonous in the US but not in Cambodia ◦ Paylooh used for rashes or fever and may have high levels of lead Birthing practices reflect hot/cold/wind ◦ May not get out of bed after birth ◦ Refuse to shower or wash hair ◦ No âm (cold) foods ◦ May consume alcohol as it is duong (hot) ◦ Postpartum period is cold

93. Exploring Global Cuisine: The Cooking of Malaysia, Singapore, and Indonesia Parts of Indonesia known as “The Spice Islands” Greatly influenced by Malays, Chinese, Asian Indians, Pakistanis, Arabs, Thais, Eurasians, Melaka Portuguese, Peranakan Numerous religious practices ◦ Islam, Hinduism, Buddhism, Christianity, Judaism ◦ Malaysia and Indonesia primarily Muslim ◦ Bali is mostly Hindu ◦ Singapore mostly Christian

94. Exploring Global Cuisine: The Cooking of Malaysia, Singapore, and Indonesia Long-grain and glutinous rice ◦ Steamed, fried, sticky balls, noodles Noodles eaten at all meals and for snacks Tropical fruits Fish, beef, poultry popular ◦ Beef and poultry are expensive except in Singapore  Singapore has abundant meat and egg dishes ◦ Pork is avoided as Muslim

95. Exploring Global Cuisine: The Cooking of Malaysia, Singapore, and Indonesia Tomatoes, potatoes, eggplants added to soups and rice Salads ◦ Often with peanut sauce Coconut Lots of seasonings Sour taste added with lemons, limes, unripe mangoes, tamarind or vinegar

96. Exploring Global Cuisine: The Cooking of Malaysia, Singapore, and Indonesia Nyonya fare ◦ From Singapore ◦ Combines Chinese (often pork-based) with Malaysian seasonings such as coconut, turmeric and lemongrass All courses served at once Dishes categorized by preparation techniques, not ingredients Forks, spoons, chopsticks, right hand used to eat Street vendors available around the clock

97. Exploring Global Cuisine: Thai Fare Climate ideal for growing rice ◦ Long-grain preferred, glutinous is used Noodles made of rice, mung beans and wheat are common Tropical and temperate fruits and vegetables Seafood, especially shrimp is popular Beef, pork, chicken, duck, dried herring-like fish popular protein foods

98. Exploring Global Cuisine: Thai Fare Differs due to flavors One of the hottest cuisines in the world! ◦ Lavish use of chile peppers Curried dishes daily ◦ Yellow is Indian-like, milder and smoother with cardamom and turmeric ◦ Red is chunkier and hotter with red chiles and coconut milk ◦ Green extremely HOT

99. Exploring Global Cuisine: Thai Fare Seasonings are basil, coriander leaves and root, galangal, garlic, ginger root, lime leaves, lemon grass, mint, tamarind Fermented fish products added to most dishes Yams, salads, noodles, dumplings, peanuts popular Began as a court cuisine Evening meal includes elaborate appetizers, elaborately carved fruits Fingers and spoons used All dishes served at once

100. Pacific Islanders

101. 10,000 Islands of Oceania Polynesia ◦ Hawaiian Islands ◦ American Samoa ◦ Western Samoa ◦ Tonga ◦ Easter Island ◦ Tahiti ◦ Society Islands Micronesia ◦ Guam ◦ Kiribati ◦ Nauru ◦ Marshal Islands ◦ Mariana Islands ◦ Palau ◦ FS of Micronesia

102. 10,000 Islands of Oceania Melanesia ◦ Fiji ◦ Papua New Guinea ◦ Vanuatu ◦ The Solomon Islands ◦ New Caledonia

103. Introduction Geography is similar with small, tropical coral or volcanic islands Racially and culturally diverse population ◦ European ◦ American ◦ Japanese

104. History of Pacific Islanders in the US Migration patterns fluid between the islands Few Hawaiians of full native heritage ◦ Many have migrated to mainland US Samoans left Samoa for Hawaii or mainland US Guamanians have enlisted in the US armed forces and moved to Hawaii or West Coast ◦ Chamorros are native Micronesians Tongans have immigrated to mainland US due to decreased economic opportunities in Tonga

105. Current Demographics and Socioeconomic Status Hawaiians are largest percentage of American Pacific Islanders ◦ Half live in Hawaii ◦ Rural and semi-rural areas in Hawaii ◦ Lowest economic strata in Hawaii ◦ Family incomes close to national average ◦ Poverty rates slightly above ◦ College attendance rates higher but graduation rates lower

106. Current Demographics and Socioeconomic Status More Samoans live outside Samoa than in both Samoas combined Mormon Samoans migrate to Mormon areas in US Low pay, large immediate families, responsibilities for family back home often lead to poor standard of living College attendance higher than average Adjustment may be difficult as their titled rank from Samoa unrecognized in the US

107. Current Demographics and Socioeconomic Status Guamanian family income just below national average Poverty levels near national average ◦ Chomorros become part of Pacific Islander communities ◦ Native Micronesians Tongan educational attainment low ◦ Median income close to national norm but sharing earnings with relatives expected May suffer discrimination and economic hardships

108. Worldview: Religion Hawaiians practice mainly Protestantism, Buddhism or Shintoism Samoans follow Methodist, Catholic, Mormon, and Anglican Chomorros primarily Catholic Tongans in the US are Mormon and immigration aided by church Often prominent in lives of Pacific Islanders

109. Worldview: Family Traditionally social rank and power established by birth order Younger siblings deferred to older brothers and sisters Elders respected Senior male managed all group matters Extended family help raise children Household composition flexible Generosity and sharing highly valued Social transgressions were responsibility of the whole family

110. Worldview: Family Still maintain extended families Childrearing shared among family Household chores assigned by age and gender Oldest man or women in home assumes control of finances, needs ◦ Good of the whole family considered before benefit to individual ◦ Guided by desire to avoid bringing shame on family Stresses of acculturation due to becoming anonymous

111. Traditional Health Beliefs and Practices Religion and medicine were traditionally linked Losses have occurred with adoption of nonnative faiths Folk healers specialize in herbs, massage, religious, and/or spiritual intervention Clientele extremely diverse

112. Traditional Health Beliefs and Practices: Native Hawaiians Believe lokahi is essential to good health ◦ Harmony between individuals, nature, gods Practice massage Herbal medicine Conflict resolution Meditation Deep breathing Chinese Traditional Medicine Healing initiated at the end of each session with spiritual blessings

113. Traditional Health Beliefs and Practices: Native Hawaiians 300 botanical, animal, or mineral-based cures available traditionally in Hawaii ◦ 58 for respiratory problems 30 used now ◦ Aloe vera for burns, HTN, diabetes, cancer ◦ Plantain leaves to reduce blood sugar ◦ Black nightshade for asthma, coughs, colds ◦ Wild ginger for GI troubles, ulcers, asthma Home remedies common

114. Traditional Health Beliefs and Practices: Samoans Maintain health by ◦ Good diet ◦ Cleanliness ◦ Harmony in interpersonal relationships High risk for illness if family or village obligations are not fulfilled

115. Traditional Health Beliefs and Practices: Samoans Balance is essential ◦ Interpersonal relationships ◦ Working too hard ◦ Sleeping too little ◦ Eating the wrong foods All cause to’ala (center of one’s being just beneath the naval) to locate to another part of the body

116. Traditional Health Beliefs and Practices: Samoans Samoan healers consulted for folk illnesses ◦ Particularly those of the supernatural  Spirit possession by malevolent ghosts  Angry ancestor spirits ◦ Muso  Mental illness in young men and women characterized by extreme withdrawal

117. Traditional Health Beliefs and Practices: Samoans Herbalists Masseuses Bone setters Midwives Taulasea ◦ For Samoan illnesses Power healers ◦ Spiritual interventions Diviners ◦ Specialize in why illnesses occur

118. Traditional Food Habits: Pacific Islanders Cooking developed without metal pots, pans or utensils Many foods eaten raw Indigenous cuisine based on breadfruit, taro, cassava, yams, and maybe pigs and poultry Fruits widely available ◦ Bananas and coconuts Influenced by European missionaries and traders and other SE Asian immigrants

119. Traditional Food Habits: Pacific Islanders Starches were mainstay of diet ◦ Taro  Poi is taro root paste partially fermented ◦ Breadfruit ◦ Cassava ◦ Yams Lots of seaweed Fish and seafood

120. Traditional Food Habits: Pacific Islanders Pork most commonly eaten meat Traditionally cooked in an imu Fire built over stones lining a pit Banana leaves or palm fronds added Then the pig and other foods placed on leaves Covered with more leaves Sealed with dirt to cook

121. Traditional Food Habits: Pacific Islanders LauLau ◦ Packets of food steamed wrapped in ti or taro leaves Chicken and eggs widely available Milk and dairy uncommon Fruits and nuts are important ◦ Haupia is a gelatin-like dessert made from coconut milk with sugar ◦ Macadamia nuts are a Hawaiian favorite

122. Traditional Food Habits: Pacific Islanders Traditionally food is not highly seasoned Lime, lemon, coconut milk or cream, and salt ◦ Ginger, garlic, tamarind, scallions or onions Coconut oil and lard are preferred fats

123. Exploring Global Cuisine: Australian and New Zealand Fare Believed to be initially populated from peoples from SE Asia ◦ Maoris are those of Polynesian and New Zealand heritage ◦ British Meat is the mainstay of the diet ◦ Beef in Australia ◦ Lamb in New Zealand

124. Exploring Global Cuisine: Australian and New Zealand Fare Lots of fruits and vegetables ◦ Kiwifruit Sweets eaten daily ◦ Scones ◦ Lamingtons ◦ ANZAC biscuits Morning and afternoon tea Australia is noted for it’s beer and wines Pavlova is national dessert

125. Exploring Global Cuisine: Australian and New Zealand Fare Aboriginal food of Australia ◦ Bush tucker ◦ Kangaroo, wombat, emu, wichetty grubs, wild plants Prepared simply over a fire, in the ashes or boiled Sweet potatoes, taro and ti plants introduced into the Maori diet from Polynesians Pit-roasting called hangi

126. Meal Composition and Cycle: Daily Patterns Traditional meals included poi, breadfruit, green bananas, fish or pork, greens or seaweed Little distinction made between foods of the meals Fresh fruits for snacks Beverages from coconut juice or sap Asians introduced teas Kava is a common drink ◦ Tastes like licorice

127. Etiquette Hospitality is an honor and outsiders exempt from traditional manners Rude to eat in front of someone without sharing in Samoa Respect shown for food, including not talking during the meal Most hosts won’t eat until a guest is satisfied Impolite to refuse food, but don’t have to eat everything

128. Special Occasions Holidays usually associated with religious affiliation Special events commemorated with feasting ◦ Pit-roasted foods In Hawaii, celebrated with a luau In Samoa preceded by a kava ceremony Hawaiians celebrate ◦ Prince Kuhio on March 26 ◦ Kamehameha Dynasty on June 11

129. Special Occasions Samoans feast nearly every Sunday, Most celebrate White Sunday ◦ Third Sunday of October ◦ Celebration of children ◦ Special service, festive meal ◦ Children waited on by their parents Guamanians celebrate Liberation Day July 21 Tonga celebrates King Tuafa’ahau Tuopu IV’s birthday

130. Special Occasions Food holds particular importance in Pacific Island cultures Sharing of food shows generosity and support Expresses prosperity or social standing Traditional gender roles defined by food interactions Gifts of food often given ◦ Never reject any item presented

131. Role of food Holds particular importance in most PI cultures. Sharing demonstrates generosity, support for family and village. Expresses prosperity or social standing Events celebrated with feasting and food eaten to excess as part of the ceremony Gender roles were defined by food interactions ◦ At 8 or 9 boys and girls were separated for training in food procurement (farming and fishing) or food preparation (cooking and food storage). Never reject a gift of food

132. Therapeutic Uses of Food Numerous botanicals used in Hawaii ◦ Pepper plant used to make kava  May be used as an analgesic or narcotic  Sedative  Teething aid for infants ◦ Noni used as a juice for numerous things ◦ Tumeric used as a blood cleanser ◦ Breadfruit made into tea  Treat highs blood sugar and blood pressure

133. Contemporary Food Habits in the US: Adaptations of Food Habits Ingredients and Common Foods Hawaii combines elements of Eastern and Western Foods ◦ They like Spam ◦ Soy sauce most common condiment ◦ Snacking prevalent Others began changes before immigration to US ◦ High reliance on imported and processed foods ◦ Consumption of native foods highest on Sundays

134. Contemporary Food Habits in the US: Adaptations of Food Habits Western Samoans in the US have a diet higher in fat and lower in protein, cholesterol and salt eaten by American Samoans Guamanians consume meats, fried foods, coconut milk, white rice, sweetened beverage ◦ Low amounts of produce ◦ Traditional foods reserved for feasting Samoans in Hawaii have greater variety of foods ◦ Minimal use of traditional foods

135. Contemporary Food Habits in the US: Meal Composition and Cycle 3 meals daily Breakfast is cereal with coffee Traditional meals for lunch and dinner ◦ Hawaiians may still eat poi Fruit more often part of the meal Sunday feasting among Samoans still believed prevalent

136. Nutritional Status: Intake Serious nutritional deficiencies uncommon in most Pacific Islander diets High calorie intake generally guarantees nutritional sufficiency Samoans in Hawaii had low riboflavin, calcium and iron intake Children in Guam consumed fruits and vegetables less than once daily ◦ Low intakes of calcium, vitamin E, and folate

137. Nutritional Status: Intake Hawaiians and Samoans have lower than average life expectancies ◦ Leading cause of death is heart disease ◦ Deaths from stroke higher ◦ High cholesterol common ◦ Hypertension higher among Native Hawaiians ◦ Higher incidence of some cancers w/lower survival rates Most fat in traditional Pacific Islander diet is saturated Guamanians have longer than average life expectancies ◦ High rates of some types of cancers

138. Nutritional Status: Intake Infant mortality of Native Hawaiians higher than national average ◦ In California, higher rates of infant deaths among Samoans and Pacific Islanders Increased risk for gestational diabetes ◦ High birth rates in American Samoans ◦ Rapid weight gain in infants

139. Nutritional Status: Intake Breastfeeding is common Early introduction of solids before 4 months of age common ◦ May introduce sweetened beverages and baby food desserts early ◦ Tooth decay a problem

140. Nutritional Status: Intake Obesity rates among the highest in the world Gain weight more with modernization Same for adults/children, regardless of where they live ◦ Native Hawiian children more susceptible to acanthosis nigricans  Hyperpigmentation disorder associated with obesity and type 2 diabetes. Overeating combined with inadequate physical exercise Overweight is the aesthetic preference

141. Nutritional Status: Intake Obesity may be related to heredity or change in types and amount of carbs consumed ◦ Can lose weight, lower cholesterol, blood pressure, decrease insulin requirements when consuming higher amounts of traditional carbs May have greater nonfat density ◦ Modify BMI cutoffs for overweight and obesity May associate thinness with illness

142. Nutritional Status: Intake Risk for type 2 diabetes is high ◦ Native Hawaiians highest rates ◦ Samoans Not insulin resistant but risk from overweight and obesity ◦ Central body adiposity is predictive Samoans may be especially susceptible to kidney damage ◦ End-stage renal failure common cause of death in American Samoan diabetes patients

143. Counseling May not take responsibility for personal health Decisions made by entire family Prefer a comprehensive approach to care Seek symptom relief and are not interested in long-term prevention or management Low compliance rates noted Often delay seeking care until symptoms are advanced

144. Counseling Language barriers Samoans expect extreme politeness in interactions Reserved conversational style May endure pain Judgmental or accusatory attitudes regarding lifestyle (weight gain) may cause them to not return

145. Counseling Greet each person with smile and handshake Eye contact expected All participants at equal physical level (sitting, standing, etc.) Keep legs crossed or close to body while seated In depth interview needed

146. Counseling Weight loss intervention in Hawaii well received using traditional food ◦ Difficult to adhere to diet long term ◦ Difficulties in obtaining fresh produce ◦ Obesogenic environment Cultural conflict in Micronesia when mothers tried to restrict intake of overweight children ◦ Food associated with love ◦ Grandparents accuse mothers of inadequate care when they perceive children as being too thin