Implicit bias in nutrition is learned.
As dietitians, we learn the leading causes of death and are told that minorities are most at risk for disease burden and death. But there isn't much education and discussion around racism as the underlying condition and as a barrier to health.
In order to unlearn this bias, we need to first examine what health really is and ask the question, What does any person require throughout their life to maintain good health?
"The health of a person and society is structured by the environment around them — is everyone getting the same access to the same building blocks of good health?" asks Ashwin Vasan, MD, PhD, assistant professor of Clinical Population and Family Health and Medicine at Columbia University and president and CEO of Fountain House, an organization that fosters community and creates opportunities, including housing and employment, for members living with mental illness.
These determinants are linked to policy, politics and political choices, he adds. "Quality of housing, schools, local infrastructure, clean water and clean air, public safety, quality of policing, quality and access to health care are all individual dimensions that have an effect on health."
The Effects of Social Determinants on Health
Racism has always been present. It's the structure upon which this country was built.
When systems — specifically, health care systems — are fundamentally racist, focusing on health in marginalized Black communities becomes an insurmountable task.
Why? Simply put, Black and Indigenous people do not have access to what they need to stay healthy.
Data from the USDA Economic Research Service show that Black and Indigenous people living in poor and rural areas have limited access to full-service grocery stores. These findings point to evidence that Black and Indigenous communities experience higher rates of non-communicable disease secondary to food and nutrition.
The redlining of grocery stores coupled with the saturation of dollar and discount stores that supply low-cost, shelf-stable items that are packed with added sugars, added sodium and synthetic fats all seriously contribute to poor health. And regularly eating these foods perpetuates generational cycles of non-communicable diseases.
For example, long-term data from five surveys examined race and ethnicity, among other social determinants, and found that life expectancy in 2015 was the lowest for African Americans, according to a 2017 study that looked at data from 1935 to 2016 in the International Journal of MCH and AIDS.
Researchers also found that the disparity gap increased over time with African Americans experiencing high rates of heart disease, diabetes, cancer, HIV/AIDS and infant mortality.
Moreover, the Centers for Disease Control and Prevention (CDC) reports that 44 percent of Black women over the age of 20 and 40.5 percent of Black men over the age of 20 have hypertension (aka high blood pressure) or are prescribed medication for hypertension.
"Policies, companies, businesses and banks don't invest in people or communities of color in the same way they invest in white communities," Deanna Belleny, MPH, RDN and co-founder of Diversify Dietetics, tells LIVESTRONG.com.
"There are examples of Black communities that have built up and thrived independent of this fact only to be sabotaged by hateful white supremacist acts (like Black Wall Street in Oklahoma and the Rosewood massacre in Florida)," she says.
"All of this has led to a disproportionate amount of BIPOC [Black, Indigenous, People of Color] communities facing less access to quality health care, health insurance, quality housing, nutrient-dense foods, walkable neighborhoods and the like."
From a practical and clinical perspective, people's risk for developing a non-communicable disease or experiencing a worsening diagnosis is directly linked to the ability to engage in healthy and balanced eating patterns, physical activity and a lifestyle that supports mental health.
The Black Dietitian Disparity
Let's be real: We need more diverse health care providers in order to equip communities of color with what they need to live healthily.
"Healthy eating, from a cultural perspective, looks different depending on the cultural foods that make up the traditional diet," notes Yvonne D. Greer, MPH, RD, owner of Y-EAT Right, which conducts workshops to promote healthy nutrition and lifestyle habits.
"Research has shown that some of the most effective interventions for the achievement of healthy nutritional profiles were conducted by nutrition professionals who resembled the population being impacted."
As of June 15th, 2020 the Commission on Dietetic Registration reported nearly 105,000 registered dietitians (RDs) in the United States. Of the total, an estimated 81.1 percent (75,711) are white and 2.6 percent (2,450) of the total population of registered dietitians are African American.
Why the dearth of representation in the field of dietetics?
"Historically, BIPOC were not allowed to practice or attain the education needed to join medical and non-medical professions. Systemic racism left a void and lag in attaining a racially and ethnically diverse population of both medical and non-medical professions," explains Laurel G. Huffman, MPH, CPH, RDN, citing a Duke University report.
The path to becoming a dietitian is not without challenges and significant expense.
"Entrance into programs [for clinical nutrition], including inorganic chemistry, biochemistry and statistics, are akin to the requirements for medical school," says Jen Cadenhead, RDN, a doctoral candidate at Teachers College at Columbia University with expertise in nutritional epidemiology, diet quality and health outcomes.
Achievement gaps among Black students are quite notable. In fact, between 1992 and 2017, the average reading score for white fourth- and eighth-graders were higher than Black and Hispanic peers' scores in each assessment year, according to the National Center for Education Statistics (NCES) report, Status and Trends in the Education of Racial and Ethnic Groups 2018.
These findings demonstrate disparities among early learners that subsequently affect their high school years and beyond. To be clear, this is not a question about Black students being able to "keep up" — it shines a light on the systemic and structural inequities and social determinants that are designed to keep them from moving forward.
It would require investing in Black communities and a redistribution of funds to schools to support high-quality education in marginalized Black communities. "More efforts also need to be made to recruit students who could be prospects much earlier in the pipeline," Cadenhead says. Many are stepping into the educational playing field already disadvantaged.
From a financial perspective, it's expensive to become a registered dietitian. By 2024, a Master's will be the base degree requirement needed to sit for the RD exam, per the Academy of Nutrition and Dietetics.
This requires being able to absorb the expenses related to a four-year undergraduate degree, as well as a Master's degree in addition to nine months of clinical rotations.
Many dietetic internships are unpaid and not eligible for financial aid. "It's a privilege to be able to work for free for a year while obtaining your RD credential; many people of color don't have these kinds of luxuries, especially when it can cost upwards of $100,000 to complete," explains Vanessa Rissetto RD, CDN.
Additionally, upon receiving the credential, the salary is not commensurate with the expense associated with obtaining it. As of 2018, the average dietitian salary was $61,210. Compare that to nurse practitioners, who made an average of $110,030, according to U.S. News and World Report.
Health Education Doesn't Address Anti-Racism
Many nutrition programs have a clinical focus with a wide variety of course offerings in the sciences, aimed for prepping dietitians to treat and counsel people with a number of diseases. However, training lacks anti-racist and anti-bias education.
To add to that, the majority of academic institutions and scientific journals are led by predominantly white educators and researchers who knowingly and unknowingly perpetuate bias. Only 17 percent of college presidents are from a racial minority and women of color are the most underrepresented group, according to the American Council on Education.
"Diversity and inclusion efforts have been a cover for not achieving racial equity, which is noticed by and harms the people they claim to want to be included," Greer points out. "It perpetuates the status quo with only an acceptable constant number of BIPOC entering the field."
Health professionals, specifically dietitians, serve people in a wide variety of settings including hospitals, long-term care and rehab facilities, doctors' offices, community-based organizations and private practices. RDs need education — and continued education — that includes cultural humility.
Many dietitians lack adequate anti-bias and anti-racist education, and that makes it harder to deliver person-centered care. The majority of the texts dietitians are required to read highlight statistics on disease rates, morbidity and mortality without a discussion or critical analysis of structural racism.
"Many RDs treat BIPOC differently and make assumptions about compliance and efficacy of treatment," notes Ellyn Silverman-Linnetz, RD, MPH.
In the early 1980s, the Academy of Nutrition and Dietetics developed its first diversity action plan. However, the current statistics reported by the Commission on Dietetic Registration reflect the continued homogeneity of the field. Dietitians are largely white women; that is a fact.
On June 5, 2020, the Academy published a message from the president and CEO, stating that systemic racism is not acceptable and outlining the actions they are taking to help make those changes.
How to Bring About Change
To help initiate change, Greer suggests applying a racial equity lens to all aspects of nutrition and dietetics. "Education, policy and procedures, funding of outreach, committee selection and hiring practices, should be made a priority."
It's clear that we are at a tipping point and change is needed.
The questions at hand — What's next? and How can we translate this into actionable steps for forwarding momentum? — remain. Here are just a few ideas that can be used on the structural and individual level, because we all know that change takes time.
What Needs to Be Done on the Structural Level
The current systems don't effectively or equitably serve BIPOC. We need to:
- Reallocate funding for public schools including school food programs. Teens eat at least five meals a week away from home, per the USDA. This is a period of rapid growth and development requiring additional macro and micronutrients. Malnourished children can't meet the physical and neurological demands of school.
- Increase access to safe affordable nutritious foods; reinvest in marginalized communities to bring grocers back, form Community Supported Agriculture (CSA) locations and/or work with community partners to bring a farmers' market to areas without full-service grocery stores. Concurrently, provide culturally relevant nutrition education with community partners to complement the shopping experience.
- Actively recruit BIPOC into educational models that support vocational learning, trade schools and academia.
- Seek out talented BIPOC students for dietetic internships and provide merit and need-based scholarships.
- Heed the demands. All bodies that educate dietitians, nutritionists and health coaches need action plans based on demands from groups such as NOBIDAN, World Critical Dietetics and Diversify Dietetics.
What You Can Do to Help
While we need to do this work across all sectors, here are some ideas for individuals that are particularly relevant in nutrition:
- Support groups and organizations actively engaged in restructuring food landscapes in marginalized BIPOC communities. Check out this shortlist of organizations working to advance Black food sovereignty by Civil Eats.
- Buy some of these healthy, Black-owned food products to help support BIPOC.
- Give time and share your expertise. If you can, offer complimentary or low-cost tutoring to BIPOC students interested in pursuing the sciences.
- Share your space and offer internships with stipends for BIPOC high school and college students. Internships are an integral part of resume building and exceedingly important for future employment.
Racism in nutrition and wellness didn't appear overnight. To rewrite the narrative, we need both systemic and individual change, with the goal being person-centered care with cultural humility.
- USDA ERS: “Food Access Research Atlas” for
- Int J MCH AIDS. 2017; 6(2): 139–164. “Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016” for
- CDC: “Health of Black or African American non-Hispanic Population” for
- CDR: “Registry Statistics” for
- Duke University:”Black History Month: A Medical Perspective: Education”for
- Bread for the World Institute”Applying Racial Equity to U.S. Federal Nutrition Assistance Programs" for
- US Department of Education: “Status and Trends in the Education of Racial and Ethnic Groups 2018” for
- US News & World: “How Much Does A Dietitian and Nutritionist Make?” for
- Journal of Critical Dietetics: “Hearing the Voices”: African American Nutrition Educators Speak about Racism in Dietetics” for