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Is American Dietetics a White-Bread World? These Dietitians Think So

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Long before she decided to help others eat better by becoming a dietitian, Jessica Wilson learned that the profession was unlikely to offer much to people like her.

Growing up as a Black girl in a mostly white area of Sacramento, Calif., she was bullied for her size and subjected to unpleasant visits with dietitians, who taught portion control with the aid of unappetizing plastic models of green beans and chicken breasts.

In her dietetics program at the University of California, Davis, Ms. Wilson was the only Black student. A single day was devoted to what the curriculum called “ethnic diets.” “It was not, ‘These are interesting and awesome,’” she recalled. “It is, ‘These are why these diets are bad. Next class.’”

Mexican food was dismissed as greasy. Indian food was heavy. Ms. Wilson was taught to prescribe a bland “kale-and-quinoa” diet. When she started treating patients — including many who, like her, are people of color or identify as queer — she learned how much those identities informed their perspectives on health, and how little she’d been taught about that.

“It makes people feel so guilty for not being able to eat what Goop would recommend,” said Ms. Wilson, 38. “I was no longer able to use the tools that had been given to me in school with good conscience.”

As the coronavirus pandemic has made Americans more aware of their health and eating habits, many have turned to registered dietitians like Ms. Wilson (or to nutritionists, who are not always required to obtain a specific education or certification). Yet the advice they get can sometimes seem more tailored to some past era than to the motley, multicultural nation the United States is in 2020.

In recent years — and particularly in the last several months, amid the national discussion about race — many dietitians have begun speaking out and reimagining the practice in a more inclusive way, often without institutional support.

Today, Ms. Wilson counsels many people of color on eating a healthy diet based on the foods they grew up with and love. Hazel Ng, 48, who runs a private practice in Alhambra, Calif., has created handouts for her Chinese clients that showcase produce found in Asian grocery stores, like bitter melon and lychees.

In June, Sherene Chou, 36, a dietitian with a private practice in Los Angeles, organized a group letter to the Academy of Nutrition and Dietetics — the largest and most powerful organization for food and nutrition professionals — outlining steps it should take to address systemic racism in the field, including antiracism training and more support for people of color. Leaders of numerous dietetics groups lent their support, signing the letter on behalf of 70,000 practitioners and students.

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Credit…Nolwen Cifuentes for The New York Times

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Credit…Nolwen Cifuentes for The New York Times

Many of these dietitians say the academy’s research, programs and articles ignore non-Western cuisines, or imply that they are unhealthy. They feel the profession places too much emphasis on consuming less and not enough on understanding individual eating habits. And, they add, it perpetuates an ideal of thinness and gender normativity that can exclude different body types and identities.

“It is a good-old-girls’ club where, as a person of color, you have to do so much to be invited,” said Jessica Jones, a dietitian in Richmond, Calif., and a founder of the inclusive dietetics website Food Heaven.

In response to these criticisms, the academy said it is working hard to broaden its ranks and resources to better reflect different cultures.

“Like other professions in health care and countless other fields, nutrition and dietetics has for many years experienced underrepresentation by persons of color in its membership and leadership ranks,” it said in a statement last week. “The academy knows change will not happen overnight. Still, we are making real progress that will create permanent change in our organization, our profession and our communities.”

The group is influential in setting the United States Department of Agriculture dietary guidelines that Americans are urged to follow; its members make up half of the 20-member committee that oversees those recommendations. In a July report, the committee acknowledged that the dietary approaches it studies don’t “qualitatively address cultural variations in intake patterns,” yet said the resulting guidelines allow a “tremendous amount of flexibility” that allows them to be tailored to an individual’s cultural and taste preferences.

The recipe database on MyPlate, the agriculture department’s healthy-eating website, includes 98 dishes classified as “American,” but just 28 “Asian” recipes and nine “Middle Eastern” ones. Though it lists 122 “Latin American/Hispanic” recipes, they include dishes like a “skinny pizza” made with tortillas. The Asian recipes include “Oriental Rice” and “Oriental Sweet and Sour Vegetables.”(A spokesman for the department said that “expanding the recipe database and other MyPlate consumer resources to reflect more diversity is one of our top priorities.”)

If the options seem narrow, they may begin with the narrowness of the profession. More than 71 percent of the nation’s roughly 106,000 registered dietitians are non-Hispanic white, according to the academy’s Commission on Dietetic Registration. Nearly 84 percent are women.

Entry requirements are steep: Practitioners must earn a degree from an accredited program, complete an internship (sometimes unpaid) or a supervised learning program, and pass a registration exam with a $200 entrance fee. Starting in 2024, a graduate degree will be required to take the exam.

“This is an expensive profession, with no guarantee that you are going to have a high salary,” said Lisa Sasson, a professor in the department of nutrition and food studies at New York University. She called the new graduate-degree mandate “unconscionable” and “an even greater barrier to people of color in our profession.”

The academy said that its charitable foundation provided more than $500,000 in scholarships and grants from 2017 to 2019 “for diverse individuals within the field,” and that those funds continue to grow.

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Becoming a registered dietitian often involves completing an unpaid internship. During hers, Alice Figueroa said, she could barely afford to buy herself food.
Credit…Akasha Rabut for The New York Times

Internships are highly competitive, and some even require the intern to pay. Alice Figueroa, 33, who runs a private practice in the East Village of Manhattan, said she struggled to afford food during her internship, even as she was advising others how to eat. Evelyn Crayton, 74, who was the academy’s first Black president, said many of the people in charge of matching students with internships are white, and may be more likely to select applicants who look like them.

Funding for dietetics programs at many historically Black colleges and universities, including Fort Valley State University and Grambling State University, has been cut since the 1970s. The number of Black dietitians fell by 18 percent, to 1,107, from 1998 to 2019, according to the academy’s Accreditation Council for Education in Nutrition and Dietetics.

Even when Dr. Crayton was president of the academy, in 2015 and 2016, she felt out of step with its other leaders. “I have heard that behind my back they called me an angry Black woman, because I raised questions,” she said. Her nominations of Black dietitians for leadership roles, she added, were frequently snubbed.

Told of her comments, the academy responded, “We were not aware of this until now, and we are very saddened to hear that Evelyn was subjected to these inexcusable statements. They do not reflect the academy’s core values and we are moving swiftly to investigate this matter.”

The profession’s exclusivity goes beyond race. Kai Iguchi, 28, a dietitian working at Rogers Behavioral Health in Oconomowoc, Wis., didn’t feel comfortable coming out as nonbinary to graduate-school classmates. “When the program itself as a culture is very cisgender, thin, white and female,” they said, “it is hard to be different and succeed.”

Mx. Iguchi said what they learned at school did little to address the unique problems that transgender and nonbinary clients face — being misgendered by their dietitians and family members, or feeling discomfort with overtly feminine imagery on health materials. Adult transgender people are also at high risk of developing eating disorders, according to a 2019 study by the Stanford University School of Medicine.

Even some dietitians who teach the standard curriculum find it wanting. “I have reached my limit with my textbook,” said Maya Feller, an adjunct professor in nutrition at New York University, adding that it doesn’t take into account social factors that often explain why people of color are disproportionally affected by health issues.

She said she was also unhappy with educational resources like MyPlate, which recommends meals like salmon, brown rice and broccoli, but not the curried chana and doubles served by her mother, who grew up in Trinidad. (After her interview for this article, Ms. Feller was hired as a consultant to help make MyPlate more inclusive.)

“If I saw that plate and then looked at my doubles, I would be like, ‘Well, my food is no good.’”

Ms. Feller, 43, tries instead to promote an “ongoing and consistent education around cultural humility” — not telling patients what they can’t eat, but considering the foods they have access to, and embracing, not stigmatizing, their cultural preferences.

It rankles Ryan Bad Heart Bull, 36, a Native American dietitian who works with the Oglala Sioux Tribe in Pine Ridge, S.D., that many of his peers praise the nutritional value of traditional Indigenous ingredients like salmon and bison, without understanding how federal government policies have made it harder for Native Americans to hunt and forage on their own land. To be ignorant of this cultural and historical context, “and then to turn around and say bison meat is one of the best meats you can eat and here are the ways you can incorporate it into your diet,” he said, “it is insulting and saddening.”

In 2019, he published a guide for the American Indian Cancer Foundation to educate Native cancer survivors about the nutritional value of their traditional foods.

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Credit…Andrea Morales for The New York Times

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Credit…Andrea Morales for The New York Times

Diksha Gautham, 27, a nutritionist in San Francisco, tells her mostly South Asian-American clientele that a healthy diet can include palak paneer and aloo tikki. As a child, she said, she harbored a “blind perception that anything that wasn’t dry-ass chicken and broccoli,” including the dal and rice her mother cooked, “was bad for me.” No nutritional database she has encountered includes Indian ingredients, so she created her own guides to healthful Indian food.

A Toronto dietitian, Nazima Qureshi, 29, has self-published “The Healthy Ramadan Guide” with her husband, Belal Hafeez, a personal trainer. It includes meal plans that adhere to fasting guidelines, with recipes like stuffed dates and za’atar roasted chicken, and exercises to give people energy going into daily prayers.

Some of Dalina Soto’s Latinx and Asian clients in the Philadelphia area have been told by other dietitians that they can’t eat white rice. “They shut down,” she said. “Either they go way to the extreme, where they are no longer eating any of their cultural foods, or the other side is, ‘I am just not going to manage my disease.’”

“My goal is to bring them in the middle,” said Ms. Soto, 32. She’ll suggest a salad alongside their rice and beans.

Still, many of these practitioners feel frustrated as they try to nudge the dietetic establishment toward change.

The profession is governed by the academy’s board. One subsidiary organization, the Commission on Dietetic Registration, sets professional requirements and fees; another, the Accreditation Council, certifies programs. Together, these entities and their majority-white leadership act as gatekeepers, their critics argue, limiting deep-rooted change.

The academy, which has about 100,000 members, funds research and hosts the largest annual conference for dietitians, the Food & Nutrition Conference & Expo. In 2016, it announced the Second Century Initiative, an effort to expand its reach and teachings around the globe.

The academy has had a diversity and inclusion committee since 1987. But, like all the academy’s committees, it is filled by volunteers. Teresa Turner, 37, a member from 2015 until May, said the academy offers the panel few “resources or benchmarks.” “Its only purpose,” Ms. Turner said, “is to make the academy look like they are doing something.”

The academy denied those assertions, saying the committee plays an active role, recommending strategies to recruit people from underrepresented groups to join the profession, and the academy, and promote their advancement.

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Credit…Mickey Welsh for The New York Times

A group that calls itself Audit the Academy (whose members include Ms. Turner, Ms. Figueroa and Ms. Chou) said the academy research it has seen is largely conducted by white dietitians studying nondiverse populations; if they study communities of color, they often do so from a white perspective. Members also see little representation of transgender and nonbinary people.

“If we are invisible in the research,” said Sand Chang, 42, an Oakland, Calif., psychologist who specializes in the transgender health and eating disorders, “we are going to be invisible in assessment and treatment.”

The academy, however, said it “offers materials, programs and educational opportunities to help its members provide care to a diverse array of clients,” including articles about treating transgender individuals.

In June, the organization responded to pressure from disaffected members by committing to developing action plans to address inequities in the profession. It has created a new Diversity and Inclusion Advisory Group, and conducted virtual forums to hear the concerns of 126 randomly selected members.

Shannon Curtis, 30, a Houston dietitian who helped found a group called Dietitians for Change, attended one of the sessions. “Although it was empowering to know that we are not the only ones screaming about this,” she said, “it was kind of a waste of time, in my opinion, because I am not exactly confident that they will take this information and put it into an action plan they will actually act on.”

Other organizations have emerged to address the inequities in the profession, like Diversify Dietetics, founded in 2018 by Tamara Melton and Deanna Belleny. It offers resources like mentors and educational materials to help students of color pass the registration exam.

In response to criticisms that it is harder for nonwhite dietitians to succeed in the profession, the academy offered an interview with Kristen Gradney, a senior director at Our Lady of the Lake Children’s Hospital in Baton Rouge. La, and one of several registered dietitian nutritionists who speak on behalf of the academy.

Ms. Gradney, 40, said that while the academy “has really missed the mark” in preparing dietitians to deal with diverse populations, it is starting to make progress. Still, she said “true change” would probably not come from the academy, but from grass-roots initiatives like Diversify Dietetics, where she serves on the advisory board.

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Credit…Courtesy of Evelyn Crayton

In 2018, Dr. Crayton, the academy’s past president, hosted a conference in Montgomery, Ala., where she lives, for World Critical Dietetics, an organization that champions a more inclusive approach to dietetics. Panels discussed the role that unconscious bias plays in education, and whether the registration exam was fair to all students.

Dr. Crayton took participants to the Edmund Pettus Bridge, in Selma, where in 1965, peaceful protesters marched for civil rights. “I could never have done that with the academy,” she said with a laugh. She said events like that could help pave a path toward sweeping change.

“I don’t know how to get to people’s hearts, but it is a heart thing,” she said. In a discipline that deals with such a deeply personal matter — one’s eating habits — “there has to be a change of heart, where people really feel empathy for groups who they are trying to include.”

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