Nutrition Counseling

Practice With Cultural Competence

America is becoming more diverse. The US Census Bureau projects that by 2060 more than one-half of the US population will comprise non-Hispanic whites. The numbers of Hispanic and Asian Americans are expected to double in the period between 2016 and 2060, and the population of Americans identifying as two or more races is predicted to nearly triple.

Despite this changing landscape, it’s difficult for many Americans of color to find an RD who shares their cultural background; as of January 2021, more than 80% of RDs identify as white. While organizations such as Diversify Dietetics are working hard to recruit a more diverse pool of nutrition professionals, a demographic shift isn’t going to happen overnight. Therefore, it’s essential that current and future RDs commit to improving their cultural competence, which calls for RDs to be aware of and manage their prejudices, eliminate stereotyping, and not assume other people share their values and experiences. Listening is key; open-ended questions position clients as the experts of their lives, experiences, and cultures.

Cultural humility is a related paradigm that, in addition to the tenets of cultural competence, calls for a lifelong learning and self-reflection process and advocating for fairer institutions and policies.

Cultural competence and cultural humility enable RDs to develop awareness of traditions and belief systems around food across cultures, as well as establish stronger relationships, build better rapport, and develop trust with clients from different cultures. Through these systems of respect, our personalized nutrition and management plans can be more successful and help individuals reach their health goals.

Below are some of the approaches I’ve found to be successful when working with diverse populations, as well as related resources and tools for self-education and practice.

1. Have non–English-language resources at the ready. Many Americans have limited English language proficiency or have hearing impairments. Printed materials should be available in a variety of languages. The Centers for Disease Control and Prevention, Oldways, and the National Institutes of Health offer printable and downloadable materials in several languages, covering nutrition information about commonly diagnosed conditions. And never underestimate the power of images; photos, food models, or anything that’s tactile can be very effective while teaching about nutrition.

Translation services are a good tool to have in the toolkit when they’re necessary. Some hospitals and clinics have translators, but there also are fee-based interpreter services from companies such as LanguageLine Solutions. Translators Without Borders offers translation services to nonprofit organizations for health and education purposes. In a pinch, apps like Google Translate can help communicate important words or phrases. There also may be a trusted friend or family member whom non–English-speaking patients can call during the appointment, or who can accompany the patient to the appointment, to help translate.

It’s also important to have appropriate resources for hearing-impaired clients. Printed materials are helpful here, but there are also websites and apps such as Signing Savvy and Handspeak that assist with translating spoken English to American sign language.

2. Research traditions, beliefs, and cultural foods. There are countless food traditions, beliefs, and dietary restrictions across cultures. For example, some Jewish families who follow Kosher dietary guidelines may not mix meat and dairy at meals. Some Muslim families may adhere to fasting rituals during the holy month of Ramadan, abstaining from food and drink from dawn to dusk for 30 days. Foods that are commonly eaten in one culture can be eschewed in another.

A great way to learn about a wide variety of cultural foods is to visit vendors other than mainstream supermarkets. Food banks, co-ops, and local markets are commonplace and may offer foods familiar to local cultures, and many cultural foods can be found online. Many of these foods, such as pig’s feet, chayote, and bitter melon, are listed in the USDA’s FoodData Central so RDs can understand their nutrient profiles.

3. Make your advice relevant. Use information garnered from your research—and, more importantly, what your clients tell you about themselves and their culture—to provide nutrition advice and recipes that are culturally appropriate. Oldways offers Diet Pyramids for heritage diets based on traditional Latin American, African, Mediterranean, and Asian foodways, which provide a framework for balanced diets that incorporate culturally appropriate foods. The National Institutes of Health offers an array of multicultural health information throughout its various departments. These materials also may feature people of color in accompanying photographs and illustrations, which is an important form of representation.

The way cultures believe disease should be treated also varies, with some focusing on a more integrative or holistic approach than typically found in Western medicine. Ask your clients about vitamins, minerals, and complementary and alternative therapies that may be commonly used in their culture. For example, supplements such as garlic, ginseng, aloe vera, and bitter melon often are used in Eastern and Western medicine. Understanding the context of how these foods and supplements are used can help RDs incorporate ideas and provide recommendations that are sensitive to the spiritual well being and traditions of clients. Equally important is the role of holistic practices such as yoga, meditation, massage therapy, and acupuncture.

If budgetary issues are a concern, RDs should be sure to communicate that healthful diets don’t need to be costly. With a bit of creative menu planning, healthful meals can fit into any budget. Organizations such as WIC and SNAP provide excellent advice on food and nutrition, including healthful recipes and low-cost cooking techniques.

4. Consult organizations. The Academy of Nutrition and Dietetics now offers courses and e-books on cultural competency and humility, and the American Diabetes Association has materials in several languages. An informative practice paper and training course is available through the Association of Diabetes Care & Education Specialists.

There’s always room to improve our cultural competence as dietitians. Through research, training, listening more than we speak, self-reflection, and advocacy, we can do better for our patients across cultures.

Thank you to my patients and colleagues who have shared information, traditional dishes, and their beliefs around food, nutrition, and health. It’s only with honesty and true expressions that I’ve learned how to promote creative, healthful diets that are as diverse and as varied as each of my individual patients and their families.

— Laurie Block, MS, RDN, CDCES, is a registered dietitian, and certified diabetes care and education specialist with more than 25 years of experience in nutrition to promote health and prevent disease. Laurie practices in New York City and La Jolla, California. She’s the author of the Type 1 Diabetes Cookbook and a proud supporter of Marjorie’s Fund, a global initiative to empower people living with diabetes.

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