If You Want to Diversify Dietetics, Start Asking the Right Questions: My Response To The New York Times
By: Dustin Moore, The American Dietitian
Tags: Dietetics, Healthcare, Diversity And Inclusion, Diversity, Nutrition

The first American Dietetic Association convention, held in Cleveland Ohio from October 18th — 20th, 1917

If this profession ever hopes to make progress in diversifying its ranks, we must recognize its extraordinary founding, the progress made thus far, and where we want to go.

The year 1920 was a banner year for women in America with the ratification of the 19th amendment, granting the vote for all women. Perhaps in the zeal of the time period, or through unforeseen cosmic underpinnings, or possibly just by coincidence, the first government legislations were passed this same year offering legal recognition and protection to a fledgling profession called dietetics. Just six years later this recognition would be further cemented with dietitians being required to earn a four-year degree and complete six months of hospital training, the only other profession rivaling such standards being medicine. It passed into the world like a whisper, but the Academy of Nutrition and Dietetics (AND) shot forth onto the scene as the nation’s first scientific women’s organization.

The significance of this achievement was a cultural milestone. At the time their efforts were labeled as heroic, culturally progressive, born on sacrifice, and maintained through integrity. Yet today, if you attempt to apply a modern lens to that founding, it’s more likely this origin is seen as not inclusive enough, prejudicial, narrow-minded, and perhaps the most sinful malfeasance of all… too white. Judging by Priya Krishna’s New York Times piece released this past Monday (link here), you’d think the Academy had origins more closely tied to the Klan, rather than a STEM organization composed of women.

As an educator in dietetics, it was challenging to read through a piece that left me with more questions than answers about how to achieve progress, and I was equally put off by what felt like many inaccurate generalizations. Regardless, it’s my desire to expand opportunities within the profession, amplify our ranks, and strengthen the cultural competency of our members. Frankly, I can’t name a dietetics educator of whom this isn’t true. But if we are ever going to get there, it is not going be done by rejecting our past, ignoring our progress, or making unreasonable and poorly considered demands of the brass.

In the spirit of mutual desire to improve the profession, there are four questions which come to mind in addressing these challenges; what should we look like, how do we get there, what is not helpful to achieve this, and what will help achieve this? And all of this still fails to answer the question — what is halting our progress in diversifying?

When you take a minute to think about it, a nebulous declaration of striving to be less white does not make for a reasonable benchmark. What should we look like? Can the 2019 national census demographics point the way? After all, by this standard, we disproportionately underrepresent nearly every major racial and ethnic identity. Hispanics make up 18.5% of the population, but as dietitians, 3.1%. Black Americans comprise 13.4% of our nation, yet only 2.6% of all dietitians. Then again, even if you achieved these numbers on a national level, odds are that wouldn’t ensure equal representation of care, the ideal target. No, the United States is a little more granular than that. Believe it or not, you’re unlikely to find many Tongans in South Dakota. The rural outskirts of Mississippi do not boast a robust Chinese American population. Even if they did, what assures their interest in becoming or seeking service from dietitians?

In short, I think it’s unfair to levy criticism at AND leadership on this issue, because setting a benchmark for its membership is a monumentally difficult task — difficult in accomplishment, if not more difficult in justification. Who gets to decide what exactly we look like? And what grounds do they have to accomplish this?

But say a benchmark is fixed. How do we get there? Critics refer to educators and organizational executives as “gatekeepers” to the profession, and while there is a measure of truth to this, it is presumptuous and grossly inept to attribute racial bias as their motivator for the disproportionate admission of White students. There is a much simpler explanation. The applicant pool. In my tenure as a program director in Southern California, I’ve never admitted a Black student to my program, but I’ve never had the chance, as I’ve never interviewed or perhaps even received an application from a Black student. Why? Probably because there are so relatively few Black dietetics students in both our program, and those local to the region. Nationwide, this is largely the same scenario. There are just disproportionately fewer minority dietetics students, which mathematically translate into fewer minority dietitians. Hence, the first major barrier to diversity is the pipeline of students into college programs. You cannot lay blame for that at the feet of AND executives or educators and this was perhaps the most disappointing part of the New York Times piece:

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.

I was shocked when I read that. On what basis does Dr. Crayton, a woman whom I have never heard a single ill word spoken of in public or private, subsume the selection criteria of hundreds of her colleagues to such a sinister and racist motivation? I can’t match students into my program if they don’t enter my applicant pool in the first place. But taking it one step further, consider this… if circumstances force me to choose between two candidates, one who is Black and the other White, but their applications are a perfect match in qualification, who do I choose? Does anyone out there possess the moral certitude and reasoning to justify why one student should be selected over the other on the basis of melanin content? This makes diversity nothing more than a quota system, and that’s horrible in it of itself.

The problem of diversity starts with how students are populated into dietetics education in the first place. But that’s only half the battle. Students can also feel disaffected as they complete their academic coursework, weakening their resolve and hurting their chances of advancing, and that needs to be addressed as well. How do we go about improving this situation?

To begin, here is what I do not see as helpful. I do not think there is much trenchant thought offered for many of the suggestions thus far put forward. Setting an outcome as your policy is a quick way to confuse everyone. Demanding financial incentives is rarely the guarantee you think it is. In a letter to the AND, sent out from the “Dietitians for Change” group, 7 of the 12 calls to action were demands to further finance members of disadvantaged groups. Two were calls to modify and expand existing curriculum. One of those calls was downright disturbing — a database for reporting microaggressions, microassaults, implicit bias, and other acts of racism. Think about that. A proposal that the AND maintain an active database that monitors and assumes malicious intent of its members? How exactly would you prove a case of “implicit bias”, when by definition, neither the accuser nor the accused would actually know that bias was being exhibited? Overt acts of racism can be managed by ethics violation, but the rest of this just sounds like a targeting system where accusations can be raised, and no defense offered.

The only part of the New York Times piece I am in lockstep with is its criticism of the 2024 graduate degree requirement. Effective January 2024, a Master’s degree is required to become a dietitian, and that will inevitably erect hurdles that regressively target students with the fewest resources. There is minimal evidence that a graduate degree will enhance practice competency, and there is strong evidence that this degree fails to significantly elevate compensation (the median difference between a bachelors and master’s degree was $2.63/hr, according the 2015 Compensation and Benefits Survey of the Dietetics Profession). If you increase the barriers without augmenting incentives, then other healthcare fields or food science, which offer significantly better pay commensurate to the academic requirements, will offer a tantalizing alternative to many potential students.

Next, in lieu of a less descriptive term, we need to stop crapping on the whole of the Academy’s efforts to diversify and stop portraying isolated examples as nationwide standards. I never once saw a “kale-and-quinoa” salad pitched in any of my dietetics classrooms (In Utah of all places!). Curriculum does not label entire ethnic cuisines as unhealthy. And there isn’t a dietitian alive who encourages anyone to eat like Gwyneth Paltrow — and if they do, they should be immediately fired. From everything I’ve read and seen, the Academy clearly wants a change, yet we still get sweeping dismissal’s such as this:

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.”

That’s hardly subtle, in terms of being dismissive. Was Mary Lee Chin, a daughter of Chinese immigrants and the chair of the Diversity and Inclusion Committee, consulted on this statement? What does she think of the efforts of the committee she runs? What do the Academy’s appointed spokespersons, a broadly diverse coalition, think about this?

Here I will cease with listing what I see as detractors, because we must also consider the question of what will actually help. Here are six suggestions, three for my fellow educators and three for administrative structure.

First, to my fellow educators, learn the names of your students. Call them by their names. I don’t know why, but for many students, there is no sweeter sound in the English language then their own name falling from your lips. They look up to you. They value your feedback. And nothing humanizes and connects you to them faster than by letting them know their name is worth remembering.

Second, in that same spirit, tell them all “You belong here.” Feeling unwanted or like an outsider is debilitating, and has sapped more than one student of their desire to carry on in their academic efforts. And whether or not this isolation is real or imagined, you can help by simply telling them that you are glad they came your way. And as a word of caution, you must mean this, because students will know if you don’t.

Third, write them letters of recommendation. Not from a template or something prewritten at their own hand. Something from you. Take 15 minutes of your time to speak personally with them and learn their wants, their fears, their hopes, their dreams. They’ll connect with you, and you’ll be stationed to better advocate for them.

Fourth, all of us can actively take part in being cultural builders of the community we want. Engage with your fellow professionals as often as occasion permits. Make friends and learn about what they do professionally. When students come to me worried that nobody can understand them or their interests, I seek their permission and connect them with someone who I think can help. If you can’t provide what they need, at the very least get them where they need to be.

Fifth, college is a little late to start attracting the talent we desire in dietetics. We need to start in high school. Send dietitians to schools to connect with students and establish early mentor programs which educate the youth, showcase our profession, and where possible, provide early engagement in health promoting activities. Give those kids a goal for which to strive, and a mentor they can look up to. Imagine how much the profession would expand, in all the right ways, if the Academy helped initiate grassroots programs with schools and students in need.

Last, if not the case already, a class on cultural and social aspects of food needs to be required of every DPD program, because listing cultural competency as a knowledge requirement may not be enough. It is not possible to teach the history, background, and heritage of every racial, ethnic, and national origin, but at the very least, there are tools you can equip students with to approach every client from an ethnically neutral perspective. My favorite comment from students who take my cultural class is how they expected it to be boring, and it wound up being their favorite.

I firmly believe that the vast majority, if not all dietitians, want to progress towards an Academy that more closely resembles the nation we wish to serve. We don’t want a single student left behind, least of all those who are marginalized or hampered by social burdens. But we can’t make any progress if we harbor and promote disdain for the legacy of a group of women that started us down this path. Nor can we ignore or dismiss the efforts of today to improve that legacy. I speak of this personally, because even as a male, that legacy is mine through an inheritance I earned. And if dietetics is your field, that legacy is yours too. And for any student who resolves in their heart, I want to be a dietitian, well, that legacy is theirs. May we all commit to preserve, promote, and advance that legacy.

*Update 12/10/2020 — An earlier version of this piece conflated the 2024 graduate degree mandate with the future education model. This was an inaccurate characterization and has been updated.