Who Gets to Be Healthy?

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A personal examination of systemic racism in dietetics and nutrition.

The dietetics industry is constantly growing, as more of us are wising up to the impact that consumption has on our well-being. In the United States, though, the industry is still overwhelmingly white.

According to recent statistics, 77.8 percent of dietitians are white — and the profession as a whole seems to pay little attention to the people whose bodies and diets are outside of what is considered to be mainstream and acceptable — in other words, thin and white.

Further, the industry can make it difficult for people of color to become dietitians.

With these disparities comes a reckoning about how mainly marginalized folks are being left out of the nutrition equation –– as patients and as professionals. That’s because health and diet aren’t just about falling in love with vegetables.

The lack of culturally diverse and culturally competent nutrition guidance that comes as a result of the field being a monoculture prevents many white dietitians from meaningfully connecting with and helping patients of color. This is particularly unfortunate because they’re often the ones who need it most.

The Black community’s poverty rate is almost double the national rate, and they are twice as likely to be food insecure than white Americans. In addition, Black, Native, and Hispanic communities are more likely to battle diet-related conditions like diabetes, hypertension, and obesity. 

One major problem for patients is that they’re often made to feel like there’s only one way to eat healthily and well, which consists of eating things like salmon, salad, and smoothies — “white people food,” in other words. This meritocratic approach to nutrition says that in order to eat healthier, you need to eat less, to eat fresh, whole foods only to get the body and health you seek.

But that doesn’t consider that people shouldn’t have to give up their cultural foods to be healthy. It also fails to consider that many social and economic circumstances influence people’s health — such as access, generational trauma, and systemic racism — and that being healthy looks different for different people. 

All foods fit — even cultural ones

Instead of encouraging cultural connections, dietetics programs and white nutritionists have a history of scrutinizing ethnic foods. For instance, Tamara Melton, RDN, the cofounder of Diversify Dietitians, wrote in Self magazine in 2018 about her experience studying to become a registered dietitian and realizing that her traditional dietetics education was not inclusive of other cultures. 

“The extent of our education in cultural competency was extremely limited,” she wrote. “We were often being taught to perpetuate the idea that Eurocentric eating patterns were the only paths to healthy eating, that healthy eating means one thing and one thing only.” 

One white nutritionist went as far as to create a “clean” version of ethnic food by opening her own Chinese food restaurant, referring to traditional Chinese American cuisine as food that makes you feel “bloated and icky.” Her menu lacked traditional Chinese dishes, and her restaurant shut down after just 8 months amid lots of unsurprising backlash. 

For a long time, I internalized some of these beliefs myself, that cultural foods are unhealthy and bad for you. In my own quest to become healthy — I once struggled with an eating disorder — I’ve had to grapple with the many Black celebrations in my life, of which food is always at the center.

I’ve seen quite a few dietitians, most of them white, to get help with my struggles. And the meal plans they’ve recommended to me, which consisted of foods like sprouted bread, flavorless low sugar protein bars, and egg white frittatas, starkly contrasted with the menus at these celebrations. 

For those unfamiliar with Black functions, they come with a set of strict rules. Church events often end with fried chicken, green beans, and a slice of pound cake that someone’s grandma made. The same goes with funeral repasts. Someone is delegated the task of making potato salad, baked mac and cheese, or deviled eggs. Anything you haven’t been delegated, you don’t make, period.  

Another rule is you don’t offend someone who puts effort into their delicious contribution. Seriously. Do you know how long it takes to peel all of those potatoes for the potato salad? Despite the fact that there is lots of love baked into every morsel, indulging in these cultural foods while trying to be healthy can make you feel guilty.

And nutrition sessions often don’t prepare you for that guilt or offer solutions, like how to straddle the line of being polite while sticking to your health goals. 

One dietitian that I saw in an inpatient setting was Black, and she created a higher calorie meal plan to accommodate Black foods, like a hearty breakfast of eggs, grits, and toast instead of cereal. At the time, I’ll be honest, I found it to be a little absurd. But in retrospect, I appreciate her approach.

She explained that it was important for me to be able to sit down to an indulgent cultural meal in order to feel connected to my family and my upbringing, rather than to just eat chickpea and edamame salad or Ezekiel toast with peanut butter, with which I had no history. Her advice certainly made Thanksgiving dinner with my family easier, since I was able to make healthy choices and still eat favorite foods, like my grandmother’s sweet potato pie. 

Texas-based dietitian Starla Garcia, RD, also chooses to focus on ethnic foods with her clients. After battling anorexia as a collegiate runner, she had to come to terms with how to be healthy without trying to erase her Mexican culture. When making peace, she was reminded of how much she needed the food that nourished her family for generations.

“I learned that when I’m homesick, eating my family’s food was healing for me,” she said. “You need to heal yourself and feed your spirit with the food of your ancestors. Doing so allows you to carry them with you.” 

Also, the basic components to various cultural foods are not inherently unhealthy — whether that’s Native American maize, Chinese bitter melon, or sweet potatoes, a staple of Black culture.

“There are reasons why there’s cactus in Mexico,” said Garcia. “These cultural foods have been sustaining for the communities, and they were full of fiber, water, all of those nutrients that we need to have normal and regular digestive processes.” 

Some people have limited access to fresher food options

Another obstacle keeping the people who most need to be healthy from getting there is access. While food deserts — areas that have limited or no access to nutritious foods — affect people of all races, Black and Brown families are most likely to live in them, according to the U.S. Department of Agriculture.

Food deserts happen because of the lack of full-scale supermarkets and transportation to real supermarkets. In urban areas, stores are often over a half mile away, and in rural areas, one could be 10 miles away. 

That means that families are doing their shopping at dollar stores and convenience stores, which only carry shelf-stable, frozen, or canned options. Convenience stores may offer an occasional tomato or prepackaged salad, but too often they are at a higher price point than an entire packaged meal. 

Fixing food deserts has always been a challenge — one that Fredric Byarm, the founder of Invincible City Foundation, is working to tackle through his organization.

One approach is to bring fresh food to low income communities rather than the other way around, which is costly and doesn’t always work anyway, according to an NYU news story. Byarm’s services include a delivery program that provides affordable produce to families and bodegas in Camden and Salem, New Jersey. 

There’s also the Healthy Corner Store Initiative, a program sponsored by nonprofit The Food Trust, which helps corner store owners increase the healthy food inventory in their shops.

Since launching in 2004, the program has seen major success in Philadelphia where, according to the nonprofit, “a network of 660 corner stores committed to healthy change has introduced 25,000 healthier products to store shelves.” This makes it easier and more accessible for families in lower-income communities to eat healthy.

Programs like these are game-changing, but some activists argue that finding solutions to food deserts aren’t always enough, considering the extent of the problem.

Longtime food activist Karen Washington, for instance, prefers the term “food apartheid.” It’s a more intersectional term that looks at the whole food system, including geography, race, economics, and more.

“You say ‘food apartheid’ and you get to the root cause of some of the problems around the food system,” Washington told Guernica in an interview in 2018. “When we say ‘food apartheid,’ the real conversation can begin.”

Generational trauma has a strong influence on people’s health

The wealth gap in the United States can point to more Black people struggling after the Great Depression and World War II, while white families were given the tools to thrive. The gap is so extreme that it would take the average Black family 228 years to obtain the same amount of wealth as white families, according to a 2016 report.

This kind of racial inequality often results in poverty, and growing up in poverty can cause people to make food choices that lead to poor health outcomes. Garcia thinks it’s important for dietitians working with this kind of clientele to acknowledge the systemic issues that lead to individuals eating what’s cheap and easy to begin with.

“It’s not that they chose these foods,” she said. “These are the resources that they have around them when they are busy and exhausted from working long hours.” 

Poor eating can also be a survival habit, one that is often passed down through generations.

For the children of immigrants or large impoverished families, they may have developed habits like finishing their entire plate, even if they are full, or eating what’s most affordable, even once they have a decent income. These habits can be a struggle to break, 2016 research says.

Systemic racism needs to be taken into account when considering someone’s health

What may also be left out of the health conversation are the consequences of systematic racism on a person’s body. 

Weathering is very real, per 2014 research. It’s defined as the physiological toll on Black people from the constant stress of racism.

One 2014 study found that this chronic exposure to stress precedes the development of type 2 diabetes. Stress is also a contributing factor for developing heart disease and diabetes, according to the University of Rochester and 2016 research, respectively.

It’s no wonder that these conditions and others are more prevalent in communities of color than in white ones, per the Centers for Disease Control and Prevention (CDC).

A dietitian may not take the effects of racism and stress into consideration when sizing up someone’s health.

Even if a higher BMI is causing someone health problems, Supriya Lal, RD, MPH explained that many factors can contribute to one’s weight, including:

  • educational status
  • a limited grasp on nutrition
  • low socioeconomic status
  • certain medical conditions
  • medications
  • family history and genetics
  • physical activity level
  • age
  • sex
  • food insecurity status
  • geographic region

    • Lal suggested that it’s up to nutritionists to keep a client’s history and limitations in mind before giving them goals for weight loss or healthy eating. This is crucial to Lal.

    “Whenever I assess a patient, I rarely just focus on a singular health condition when treating them,” she said. “I assess overall health and most importantly, take into account their individual goals before recommending any solutions.”

    Healthy looks different for different people 

    Lal also explained that someone isn’t automatically “unhealthy” because they have a consumption-based diagnosis, like type 2 diabetes or obesity. A 2017 study found that individuals who were overweight and exercised had no increased risk of cardiovascular disease.

    Living in a larger body doesn’t always give a picture of how active or healthy someone is.

    Plenty of individuals in larger bodies are just as active as thin people. Consider Jessamyn Stanley, who is a yoga instructor, and Mirna Valerio, who is an ultramarathoner. Think about how many people you know in thin bodies who struggle to run 3 miles, let alone 26-plus.

    Also, consider my thin white friend who is in the middle of a run streak (over 500 days of consecutive running to be exact) who has high cholesterol. Her doctor attributed it to genetics, while someone in a larger body, and in particular a larger Black body, would probably be told to lose weight. 

    How the dietetics industry is diversifying — and the barriers that still exist

    While my experience with my Black dietitian helping me incorporate cultural foods into my diet may have been rare in 2009, Lal believes that up-and-coming dietetics programs lean into treating patients from all backgrounds. She is witnessing firsthand how the evolving industry can impact the lives of marginalized groups.

    While the United States and Lal’s native Canada have lagged with identifying social determinants and systemic issues, Lal acknowledged that, in the past 5 years, “there has been a more conscious effort by BIPOC [Black, Indigenous, and People of Color] dietitians to create space for more people of color to become dietitians, create mentoring opportunities, more equitable access to programs, and more awareness around cultural competency.”

    Lal recently finished her dietetic internship at Duke University Health System in June 2020, and she stated that cultural competency was woven into the curriculum. That included being able to communicate through a translator and counsel patients from backgrounds different from her own.

    “We learned how to address culturally relevant foods in our recommendations,” she said.

    Still, Lal feels that the path to becoming a dietitian is “time intensive, tenuous, and costly,” and that the process adds up. Many with privilege fail to recognize all cost factors, including books, tutors, memberships, and travel.

    “Each step in this journey has certain incurring costs, ranging anywhere from a few hundred dollars to many thousand, depending on the institution attended,” she said. “As such, the field of dietetics caters in many ways to those who are able to afford and absorb these added expenses.”

    Another roadblock will begin in 2024, when the degree requirement to take the registration examination for dietitians will change to a graduate degree from a bachelor’s.

    Despite her ultimate success years earlier, Garcia believes that the path to becoming a dietitian can be exclusionary, as well. She has battled with the socioeconomic barriers, from costly examinations and low paying internships that are difficult to land. A low paying or unpaid internship could be costly to a person of color in the long run, considering how much debt they may already carry.

    Black women have the highest amount of student loan debt of any other group, according to a 2021 report. And while Native Americans may borrow less, their monthly payments are higher than other ethnic groups. They’re more likely to pay over $350 a month toward debt.

    That said, Garcia would love to see more support for students of color who’d like to get into dietetics, including scholarships and mentorship opportunities.

    Diversify Dietetics (DD) is a nonprofit organization seeking to empower future dietitians of color in precisely these ways.

    The organization seeks to help people of color overcome the various barriers to entering the field, offering scholarships and hosting events tailored to marketing yourself and even tending to the needs of marginalized patients.

    Last year, Lal worked as a mentor at the organization, assisting her mentees with resource selection and referrals, networking, and more. 

    While DD was started by Black women, the Black Lives Matter movement has caused other programs to bring the plight of minority professionals to focus. The Academy of Nutrition and Dietetics and All Access Dietetics have increased their focus on diversity and inclusivity for dietitians and students.

    That includes:

  • a report on health equity geared toward Academy members (aka dietetics and nutrition professionals), which talks about social determinants of health
  • two new $25,000 scholarships to be awarded to students of color to pursue their education from the Academy
  • a diversity guide for dietitians in training from All Access Dietetics

    • Garcia expressed that, even though work still needs to be done in dietetics, her white colleagues have been vocal about the need for cultural competency. She also asserted that diversity and inclusion education can lead to lasting changes in dietetics, and that her colleagues must ask: “What else can I learn or do to really bridge the gap? Are my resources or the things I’m talking about culturally sensitive to my client?”

    She added, “The same way that cultures have had to understand their history at a deep level to understand where they’re going, I think that my peers need to examine the industry in the same way.” 

    Lal is hopeful about the future of dietetics.

    “I believe that the tides are turning to be more sensitive to the barriers that marginalized groups face in the journey to becoming an RD [registered dietitian],” she explained, pointing to the expanded scholarship and mentorship opportunities, and the increased emphasis on helping those who come from disadvantaged communities or backgrounds.

    “I hope that the increasing awareness continues,” she said. 

    I do, too. 

    Tonya Russell is a New Jersey-based writer with a passion for health and wellness. When she isn’t writing, she’s probably hiking with her dogs or training for a marathon. 

    Posted : 2024-08-29 10:50

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