By: Deborrah Lee, Cora Ragaini , and Renee Warner

1. The Middle East By: Deborrah Lee, Cora Ragaini, and Renee Warner Morrison Chartwells Dietetic Internship Cultural Practices Group Project 2/15/12

2. Objectives • Learn about the geography, people, culture, and the dominant religion to gain an overall understanding of the Middle East. • Know the staple foods in the Middle Eastern diet. • Be able to recognize traditional health beliefs and practices, and familiarize oneself to the prevalent diseases of the region. • Be knowledgeable in counseling techniques and be effective in cross-cultural communication.

3. What is the Middle East? • One of the oldest regions in the world. • Contains about 15 countries. • ME is at the junction of trade routes connecting Europe, Asia, Africa, and the Mediterranean basin. • Diverse population. • Resourceful land.

4. The Land • Landscape- Deserts, mountains, rivers, fertile soil, petroleum. • Euphrates, Tigris, Jordan, Nile River, Persian Gulf • The Fertile Crescent • Two-thirds of world’s known petroleum • Weather- hot and dry summers (June-August); humid and rainy winters (December-February). • Foods- where wheat was first cultivated, others include olives, figs, lemons, coffee, chickpeas, barley, flax, peas, lentils, pomegranates, asparagus, etc.

5. The People • A region of many ethnicities, languages, and religions with a population of 305 million people. • 1.8 million in the US which makes up about .5% of our population • Ethnicities- Arabs constitute the majority ethnic group except in Iran (Persian), Turkey (Turkic), and Israel (Jewish). • Language- 60% of total population speaks Arabic. • Religion- Islam is the dominant religion in all of the Middle Eastern states except Israel.

6. Islam • People who practice Islam are referred to as Muslims. • 5 pillars of Islam: the five basic acts considered obligatory for all believers. • The Shahadah- basic creed of Islam • Daily Prayers • Almsgiving • Fasting • Pilgrimage to Mecca

7. Fasting • “Ramadan”- the month of obligatory fasting for all mentally and physically fit Muslims. • Ninth month of the Islamic calendar lasting 29-30 days. Dates vary every year. • Must refrain from eating, drinking, smoking, and sexual intercourse during daylight hours. • Exemptions: Children, the elderly, the sick, travelers, pregnant women, women during menstruation.

8. Islamic Dietary Laws • Muslims are restricted in their diet. • Prohibited foods include pork products, blood, carrion (carcass of dead animal), and alcohol. • All meat must come from an herbivorous animal slaughtered in the name of God by a Muslim, Jew, or Christian with the exception of game that one has hunted or fished for oneself (also known as “Halal meat”). • Permissible or acceptable food is known as “halal” food.

9. What is the Mediterranean Diet? • The diet of the Middle East and the Mediterranean is one of the healthiest in the world. It is traditionally lower in saturated fats and high in monounsaturated fats and omega-3 fatty acids.     • Studies have shown that this diet leads to a reduced risk in overall cardiovascular mortality, less incidence of cancer and cancer mortality, and a reduced incidence of Parkinson's and Alzheimer's diseases.

10. Traditional Foods and Dishes • Although there are many different countries, their dishes consist of many common items. • Bread is a staple and usually accompanies every meal.  • Dairy products are served in the fermented form such as cheese and especially yogurt. Whole milk is consumed but it is used for making desserts and puddings and not served with a meal. 

11. Staple Foods • Lamb- became the meat of choice for many meals, since pork is generally not consumed. • “Halal meat” (slaughtered in the name of God)- preferred meat depending on religious practices. • Legumes- black beans, chickpeas, lentils, navy beans and read beans are also included in many dishes. • Wheat or Rice- Each meal is accompanied by either one, usually pita or unleavened bread. Phyllo dough is also popular and used to make the well-known dessert “Baklava”

12. Fruits and Vegetables • The consumption of fruits and vegetables in this diet is fairly extensive. • Fresh is preferred if available. • Eggplant is one of the most popular vegetables used. • Dishes will often have vegetables stuffed with rice or meats. • Olives and olive oil are very common.

13. Middle Eastern Sample Menu • Breakfast: Arabic coffee or mint tea, yogurt drizzled with olive oil, plate of olives, flat bread, feta cheese and a plate of vegetables (cucumber, tomato, radish, peppers and parsley) • Lunch: Baba Ganoush (smoked eggplant mixed with tahini puree), hummus and pita bread, olive and orange salad, coffee or tea. • Dinner: Kofta (kebabs) in yogurt sauce, rice, Tabouli (parsley salad), lentil soup, coffee, or tea. • Dessert: Baklava (phyllo dough layered with butter, cinnamon and nuts baked, then topped with a honey syrup) or stuffed dates.

14. Traditional Health Beliefs • Family and Affiliation- family is the central social institute. During illness family needs are exemplified. Family deals with health issues collectively and bad news delivered to the family members first. Elders are looked to for comfort and advice. • Physical vs. Mental state- distinction is often lacking. • Germ Theory- believe that microorganisms are the cause of many diseases. • Physically robust believed to be healthier than one who is thin. • Generally have respect for Western medicine. May prefer male doctor.

15. Health Beliefs- Illness • Cold and dampness- emotional upset or carelessness • Good health vs. Bad health • Health is associated with good luck, wealth, and considered a gift from God. Sickness is associated with bad luck, poverty and considered a punishment from God for one’s sins • Evil eye- the belief that a person is looking at another with hatred or envy can provoke harm or illness. • “Death is a destiny created by God.”

16. Traditional Health Practices • Humoral Theories • Hippocratic-Galenic (or Graeco-Persian-Arab) • Derived from the word “humor” meaning “fluid” • 4 Humors: Black bile, Yellow bile, Blood, and Phlegm • Blood Letting • Cupping

17. Practicing Humoral Theories and Diet • Modern day practice of humors- Treatments include the use of opposing or regulating external activity such as diet, exercise, and sleep; bringing balance to the body. • Diet- rules to be applied to everyday life. • Factors affecting the combination of the 4 Humors in the body: cooking techniques, seasonings, combining food/drink • Avoid eating incompatible foods at same meal. Pair foods together based on opposing humors. • Cold foods paired with hot foods, like melon with prosciutto and pork with mustard. • Herbs and spices have often been used to counter a food’s natural humoral balance. • Culinary traditions we enjoy today can trace their roots to Humoral Theory.

18. Prevalent Diseases and Conditions • Beta Thalassemia- most common preventable genetic disease. Blood disorder causing lifetime of chronic illness and early death. • Sickle Cell Disease • Phenylalanine Hydroxylase deficiency • Glucose-6-Phosphate Dehydrogenase deficiency • Celiac Disease* • Lactose Intolerance* • Obesity, Hypertension, and Diabetes on the rise in the US

19. Lactose Intolerance • Is the inability to break down the sugar lactose found in milk or milk products. This occurs when the production of the enzyme lactase is insufficient and unable to process high lactose consumption. • Studies have shown a higher prevalence of lactose intolerance amongst Middle Easterners. Genetically, people of this culture have a reduced expression of the allele for lactase. These low levels in early childhood are what lead to the intolerance. • Reduced amounts of dairy products can cause a concern for calcium consumption. However, people of the Middle East tend to consume a diet that provides other opportunities for calcium consumption such as yogurt and cheese with meals and adequate vegetables containing calcium.

20. Celiac Disease • Digestive condition triggered by consumption of gluten, which is found in wheat, barley, and rye. • Wheat has been the major staple food in this region. • Studies show a possible link between the high level of exposure to wheat proteins, celiac disease, and the population. • Prevalence: 2.1% and on the rise. Among high risk groups, such as people with positive family history or Type 1 diabetes, is up to 44% • Symptoms, Treatment, and the Role of a dietitian

21. Counseling • Middle Easterners who live in America tend to accept the conduct of American culture. • More awareness leads to better rapport, more trust, respect and an increased willingness to accept advice given. • Knowing common practices in their culture will enhance your skills and impact as a clinician.

22. Men and Women: Divided • In this culture, men and women are considered separate and not equals. • Touching, shaking hands, and hugging is not acceptable between people of the opposite sex. • Extended eye contact between men and women is seen as a sexual overture. • Women will often turn to their husbands or fathers when making decisions about their health. • Female clinicians may have a tough time in gaining trust and respect when speaking to male patients and/or family.

23. Tips of the Trade • Body language and atmosphere • Direct eye contact is expected and necessary for understanding • Left hand is used to clean oneself, therefore, is not used for other social interactions • They prefer to build a sense of relationship before discussing the business at hand.

24. Last thoughts… • Cross-cultural communication is a skill to be developed and first starts with understanding other cultures. This is a powerful way for one’s interactions to be effective towards others. • Being sensitive to different lifestyles, beliefs and traditions can lead to more positive health outcomes. • While it is useful to apply generalizations when learning about cultures, it is also important to avoid applying hard rules in cross-cultural interactions and see the individual in any health care encounter.

25. Additional Educational Resources & References • http://dictionary.reference.com/browse/middle+east • www.culturediversity.org • http://middleeast.about.com • www.worldatlas.com • http://www.cotf.edu/earthinfo/meast/MEpeo.html • http://www.pbs.org/wgbh/globalconnections/mideast/themes/geography/index.html • http://ohioline.osu.edu/hyg-fact/5000/pdf/5256.pdf • www.mayoclinic.com/health/mediterranean-diet/CL00011http://www.mayoclinic.com/health/celiac-disease/DS00319 • World J Gastroenterol. 2010 March 28; 16(12): 1449-1457 • Kittler, P. and Sucher, K. "Food and Culture" 5th edition, p. 407-425, 2008