Nutrition Professionals Feel Underprepared to Serve Persons With Marginalized Identities

Abstract

With increasing attention on diversity, equity, inclusion (DEI), it is necessary that nutrition professionals are educated and trained to provide inclusive care for all individuals. Yet, little is known about how nutrition students are educated and trained to serve persons with marginalized identities. Using the Diffusions of Innovations Theory, the purpose of this study is to identify early adopters of inclusive approaches to dietetics care and understand their preparedness to serve marginalized persons. This descriptive pilot study used a virtual intercept interview approach using poll style questions in a Facebook group (#InclusiveDietetics) dedicated to sharing content about DEI in dietetics, as members of the group were identified as “early adopters” of inclusive care. Five questions assessed the type of education, diversity of educators, and sources of information that nutrition professionals used to learn to serve marginalized clients. Descriptive statistics (counts and frequencies) were used to analyze the data. About 79.31% of participants reported receiving no education or training from their accredited dietetics programs interacting with patients with mental disabilities, physical disabilities, identifying within the LGBQ+ and Trans community, and of different cultural/racial/ethnic backgrounds. When they received it, nearly 75% of participants reported receiving training on working with patients of different racial/ethnic backgrounds but only 5.56% reportedly received training to serve persons within the LGBTQ+ community. Nutrition professionals feel prepared to interact with marginalized groups to some extent; however, more research, education, and training are needed to develop best practices and adequately prepare professional to serve marginalized patients.

Keywords

diversity bias dietetics education health professions education inclusion

Introduction

The number of persons who identify with a minority or marginalized group has increased and is predicted to continue to increase in the United States. Recent data indicates a consistent increase in LGBTQ+ identifying population since 2012 (currently 5.6%) among United States (US) adults (J. M. Jones, 2021), increases in adults who identify has having a disability (Okoro et al., 2018), and a declining white population (with increases in those who identify as Hispanic or Asian; Frey, 2020). With an increasingly diverse population, it is important for nutrition professionals to be knowledgeable about and prepared to provide inclusive care to individuals, in order to facilitate better health outcomes and overall wellbeing (Burt et al., 2018; Setiloane, 2016). Cultural humility, care tailored to an individual’s unique cultural identities (based on personal identity and provider self-awareness), has been utilized by healthcare professionals as a means to build honest, trustworthy relationships with patients of diverse backgrounds and improve patient outcomes (C. T. Jones & Branco, 2020; Yeager & Bauer-Wu, 2013). A provider who has cultural humility will provide more culturally humble (or culturally tailored) care. Recently, nutrition professionals have emphasized the need for more cultural humility within higher education and in training programs in order to provide culturally humble care to individuals of all identities (Wahlstedt et al., 2021).

The Accreditation Council for Education in Nutrition and Dietetics (ACEND) mandates competencies for accredited dietetics programs and at the time of this pilot study, ACEND standards require programs to provide “cultural competence education” (2017 Standards and Templates, n.d.). Of note, the term “cultural competence” is a slightly dated term, which has been updated and expanded to “cultural humility”: cultural competence was defined as a knowledge of other cultures whereas cultural humility expands on this idea to all that self-awareness and a knowledge of one’s implicit bias is also a key factor to culturally tailored care (Yeager & Bauer-Wu, 2013). ACEND’s standards reflect the older, but still commonly used term of cultural competence. Nonetheless, exactly how ACEND or individual programs define culture or cultural competence is unclear, as are the expectations for knowledge outcomes for students who receive cultural competence education; for example ACEND indicates “cultural competence,” “diversity,” and “sensitivity” should be taught but doesn’t provide guidance as to how (2017 Standards and Templates, n.d.). More specific guidance from ACEND has been cited as a way to improve cultural humility (Lund et al., 2020). Some educators and preceptors may narrowly define culture as racial/ethnic culture while others may consider culture as a social construct describing identification within a community. In that way, “cultural humility” may be broadly defined as serving different social groups, including geographic-based groups (country/regional affiliations, like Dominican), trait-based groups (e.g., gender identity), or even value-based groups (e.g., vegetarian/vegan). Without guidance from ACEND, it is unclear what groups dietetic students and interns are being trained to serve and there is likely massive variation between programs. Moreover, there are myriad nutrition undergraduate and graduate programs that are not accredited but produce nutrition professionals and the educational standards and topics taught in those programs are entirely unknown.

The lack of diversity and inclusion among credentialed nutrition professionals (Registered Dietitian Nutritionists, RDNs), and therefore educators and preceptors, is also of concern (Burt et al., 2018). A diverse and inclusive profession is needed to develop cultural humility and better serve a diverse population. While there is very little data available about non-conforming gender, sexual, or ability diversity (or other marginalized identities) within dietetics (Burt, Ruder, & DeBiasse, 2021), RDNs are overwhelming white, female (Commission on Dietetic Registration, n.d.). As a result, the lens of dietetics education is the white perspective. Diverse faculty perspectives are critical for developing cultural humility and promoting diversity within higher education and academic communities (Diaz et al., 2020), and the lack thereof may be limiting the cultural humility of dietetics professionals.

Despite compelling reasons to integrate more education about serving marginalized populations, few studies examine what education or training nutrition professionals receive and how prepared they feel to work with these populations. Therefore, the objective of this pilot study is to determine how adequately prepared nutrition professionals who demonstrate an interest in diversity, equality, and inclusion feel on interacting with patients with marginalized identities.

Methods

This pilot study explored the preparedness of nutrition professionals to serve persons with marginalized identities through a series of poll questions conducted on the social media platform Facebook.

Theoretical Framework and Participants

The Diffusion of Innovation theory, which describes how an innovation spreads over time among people in a social system, was used to identify participants for this study . Depending on three different variables (characteristics of the innovation, characteristics of adopters, and environmental setting), an innovation may be adopted by individuals and diffuse through social groups at different rates that follows the pattern of a bell curve (Rogers, 2003).

The innovation identified for the current pilot study was the interest in learning and adoption of more inclusive approaches or practices in dietetics. At the time participants were recruited for this study, bias (and equity and inclusion in general) was of interest but not prioritized in dietetics. For example, in an email to members on June 5, 2020 (about 4 months after this study began), the Academy of Nutrition and Dietetics issued a statement alluding to their lack of progress, with the first lines of their email stating “Systemic racism is not acceptable. . . .You are asking for more and you told us that the Academy can do better: We agree” (Farr, personal communication, June 5, 2020).

While the Academy was seemingly acknowledging their lack of progress on inclusion and committing to improving inclusion in their statement, the difficulty of doing so became apparent over the next year. For example, about 6 months later, dietetics was facing a public reckoning with internal racism and bias when a New York Times article was published confirming that racism was prevalent in dietetics education and practice (Krishna, 2020). At the same time however, other professional organizations (presumably not entrenched in intraprofessional debate) were naming racism as a major driver of health inequities. For example, the American Public Health Association (2020), issued a very strongly worded statements calling out “structural racism is a public health crisis”. Importantly, at the time of this study (and at the time of publication in 2022), neither structural racism nor systemic racism have been named by the Academy of Nutrition and Dietetics as drivers of inequities, highlighting that dietetics may be behind other health professions in its approach to bias against marginalized groups.

The Diffusion of Innovation Theory identities are five types of adopters: innovators, early adopters, early majority adopters, late majority adopters, and laggards. Innovators (only 2.5% of the population) and early adopters (13.5% of the population) comprise the first individuals to engage with a particular innovation. In the current pilot, researchers identified the existing #InclusiveDietetics (#ID) group as the forum for this study, as it is a public Facebook group that convenes nutrition professionals with an interest in diversity and inclusion in the profession. The approximately 1,500 members of #ID at the time of this study were identified by researchers as “early adopters” of an inclusive approach to dietetics practice.

Early adopters of an innovation are individuals who recognize a need for change and are comfortable adopting new ideas (Rogers, 2003). Since #ID members took initiative to join one of the only existing group focused on diversity and inclusion in nutrition, they have demonstrated interest in improving inclusion. While there may be many reasons to join #ID, members of the group indicated how much they value diversity, equity, and inclusion in dietetics in a screener questionnaire prior to admission, confirming their value of and interest in driving change (Burt, Debiasse, & Qamar, 2021). Early adopters do not necessarily need evidence that an innovation works before they are willing to adopt it (Rogers, 2003), which is a particularly important trait for the current pilot study since evidence about how to serve persons of marginalized identities is limited (particularly for persons of non-conforming gender or sexual identities, of varying abilities, or who are neurodiverse; Burt, Ruder, & DeBiasse, 2021). While #ID members are not the only early adopters of inclusive dietetics practices, they were an accessible group since a founder and moderator of ID is the senior researcher on this pilot study.

Data Collection and Analysis

A series of five poll questions were developed by the researchers to understand if nutrition professionals were educated about and felt prepared to interact with the following marginalized groups: persons with mental disabilities, physical disabilities, identifying within the LGBQ+ and trans community, and of different cultural, racial, and ethnic backgrounds. All questions and answer options are presented in Table 1 (see Results Section) and are presented in the order they were posted. It is unknown exactly how many #ID members viewed each question. Since participants were only presented with one question every other business day for 10 days, the exact sample of participants varied; that is, whether a participant responded to a single question or all five questions is unknown. This pilot study was approved as an exempted amendment to the parent study by the Lehman College Institutional Review Board (protocol # 2019-0620). No personal identifying information was collected from participants.

Table 1.

Questions and Response Options (in Chronological Order of Posting) in the #InclusiveDietetics Facebook Group to Understand Dietetic Professionals Preparedness to Serve Marginalized Patients.

Questions	Answer options	n (%)^a
Where, if anywhere, have you received education or training on interacting with patients with mental disabilities, physical disabilities, identifying within the LGBQ+ and Trans community, and of different cultural/racial/ethnic backgrounds on your own or during your formal dietetics’ education? (n = 58)	Received education/training on my own	32 (55.2)
	Received education/training in my accredited program	0 (0.0)
	Both on my own and in my accredited program	12 (20.69)
	Neither—I have never been educated or trained to work with persons in marginalized group	14 (24.14)
We are curious about which marginalized groups, if any, you have been formally educated (e.g., in a DPD/CP/FEM/DI program) about or trained to serve? (Choose all that apply; n = 36)	Mental disabilities	9 (25.0)
	Physical disabilities	14 (38.89)
	LGBQ+ and trans/non-binary community	2 (5.56)
	Different race/ethnicity/cultural backgrounds	27 (75.0)
	None of the above	5 (13.89)
During your formal dietetics education (e.g., DPD/CP/FEM/DI), who taught you about interacting with patients with mental disabilities, physical disabilities, identifying within the LGBQ+ and Trans/non-binary community, and of different racial/ethnic/cultural backgrounds? (Choose all that apply; n = 35)	White people	29 (82.86)
	People with physical/mental disabilities	1 (2.86)
	People within LGBQ+ and trans/non-binary community	3 (8.57)
	BIPOC (people of color)	8 (22.86)
	Not sure about how those professors/preceptors identify	2 (5.71)
	None of the above	3 (8.57)
Please indicate all of the sources of information (formal, through DPD/CP/DI/FEM, or informal, through professional organizations, personal reading/research, etc.) from which you received knowledge/skills about interacting with patients with mental disabilities, physical disabilities, identifying within the LGBQ+ and Trans community, and of different cultural/racial/ethnic backgrounds? (Choose all that apply; n = 16)	Class presentation	2 (12.5)
	Webinars	15 (93.75)
	Research article(s)/poster	7 (43.75)
	Assigned readings/assignments	5 (31.25)
	Hands-on experience	7 (43.75)
	Social media platforms (e.g., Facebook, Instagram, Tik Tok, etc.)	12 (75)
	Ted Talk (or other formal lecture series)	6 (37.5)
	None of the above	0 (0.0)
In general, how prepared do you feel to interact with people with mental disabilities, physical disabilities, identifying within the LGBQ+ and Trans/non-binary community, and of different cultural/racial/ethnic backgrounds? (n = 17)	Well-prepared	6 (35.3)
	Somewhat prepared	8 (47.1)
	Somewhat unprepared	1 (5.9)
	Very unprepared	2 (11.8)
	Unsure	0 (0.0)

Since participants could choose more than one answer option for some questions, percentages don’t always add up to 100%.

All five questions were posted within two consecutive weeks in April 2021. The senior researcher (and a founder/moderator) of #ID posted questions at 11 am EST on Wednesday and Friday during the first week of the study and Monday, Wednesday, and Friday the following week, in the #ID group using the “poll” feature. The time of posts was selected based on informal research of the best times to engage Facebook users based on their activity during the COVID-19 pandemic (Social Sprout, n.d.). For each question, the number of participants who selected each response option was recorded 48 hours after the question was posted. Descriptive statistics were used to analyze the data.

Results

Since each poll question was posted at a different time point and participants were not tracked across questions, there is no total sample size for this pilot study. A total of 58 participants answered the first poll question; 36 answered the second; 35, 16, and 17 responded to the third, fourth, and fifth question, respectively. The number of responses to each answer choice is shown in Table 1.

Many participants (55.17%) reported only learning about interacting with marginalized groups on their own (no formal education or training) and 24.14% of respondents reported never receiving education or training to work with individuals with marginalized identities. Three quarters (75%) of participants reported receiving education about working with patients of different races, cultures and ethnicities while only 5.56% received training on serving patients who identify as non-binary or as LGBTQ+. More than a third (38%) of participants received training on serving patients with physical disabilities and a quarter (25%) received training to serve persons with mental disabilities.

The educators and preceptors delivering education or training in accredited programs, overwhelmingly present with dominant group identities. That is, 82.86% of participants reported receiving formal training on working with marginalized communities from white educators or preceptors. Only 22.86% reported receiving training from educators or preceptors of color, 8.57% from persons who openly identified as LGBTQ+, trans, or non-binary, and 2.86% from educators/preceptors with physical or mental disabilities. Of all types of education and training (including within accredited dietetics programs, self-study, webinars, or other workshops through professional organizations), nearly all participants (93.75%) reported receiving information about serving patients from marginalized groups from webinars. Other popular sources of information included social media (75%), research articles or posters (43.75%), and 43.75% through other hands-on experience (not necessarily associated with training in accredited programs).

The final study question gauged participants confidence in serving participants who identify with marginalized groups. Participants felt well-prepared (35.3%) or somewhat well-prepared (47.1%) whereas only 5.9% felt somewhat unprepared and 11.8% very unprepared.

Discussion

The results of this study indicate that while early adopters of an inclusive approach to dietetics feel somewhat prepared to serve patients with marginalized identities, most did not receive training to do so in their accredited dietetics programs. They train largely through self-guided study (the sources of which are unknown from this study). Individuals in later stages of innovation adoption (e.g., early majority, late majority, and laggards, who comprise most of the population), demonstrate more hesitation and wait to adopt a new innovation until it’s been shown to be effective or useful (Rogers, 2003). As a result, individuals in later stages of adoption are less educated, trained, or prepared to serve persons within marginalized communities. At best, these findings indicate a critical weak point of dietetics training in which dietetic professionals are not prepared to serve underserved populations. Though there are no other studies exploring cultural humility education in dietetics curricula, evidence of a white, heteronormative lens in health professions education has been established (Paton et al., 2020). The findings of this study are an early indicator that dietetics education may be suffering from a biased curriculum.

Few participants in this study received information about serving marginalized populations in their formal nutrition education or from class presentations. These results are similar to other research which notes the lack of education around topics such as cultural humility and competence, LGBQ+ and trans health concerns, and how to provide nutrition care to people with disabilities (C. T. Jones & Branco, 2020; Lund et al., 2020; Okoro et al., 2018; Perkin & Rodriguez, 2013). Some of this research, in dietetics students specifically, reported a lack of courses and time allotted within their formal dietetics education about cultural awareness and sensitivity (Lund et al., 2020). The results of this study contribute to the growing body of research indicating gaps within dietetics education.

Although older research indicates inconsistencies in dietetics education around cultural competence (Kessler et al., 2010; Knoblock-Hahn et al., 2010; McArthur et al., 2011), about 75% of participants in this study reported receiving formal education on interacting with people of different race/ethnicity/cultural backgrounds. This could be related to the implementation of ACEND’s cultural competency standards and the historical emphasis on racial and/or ethnic diversity when providing education around cultural competency (2017 Standards and Templates, n.d.). Examples of programs aimed to improve racial/ethnic cultural competence include interprofessional education, service learning, educational workshops, assigned cultural literacy readings, and classes focused on racial/ethnic cultural competence (Lambert et al., 2012; McCabe et al., 2020; Perkin & Rodriguez, 2013). ACEND has also approved revised standards (for adoption in 2022), which increase the depth and breadth of topics identified for mandated cultural competence education (2022 Standards and Templates, n.d.). However, there are no structured guidelines for implementing cultural competence education such as: how much time should be allotted, what populations are of interest, or how to define an adequate amount of competence. This has led to variability in nutrition professional’s knowledge and confidence in working with racially/ethnically diverse populations (McCabe et al., 2020). In response, dietetic professionals have challenged ACEND’s standards and expressed the need for more specific guidelines (Lund et al., 2020; McCabe et al., 2020).

Although working with people with physical and mental disabilities is becoming increasingly prevalent for professionals, relatively low proportions of participants in this study reported receiving formal education about serving patients with physical and mental disabilities (38.9% and 25%, respectively). Yet, providing care to people with physical and mental disabilities is an important part of the dietetics curriculum. As part of the Nutrition Care Process, nutrition professionals need to identify physical and mental disability status in order to be able to create an appropriate and safe intervention plan for the patient (Nutrition Care Process, n.d.). For example, patients with eating disorders need a different type of nutritional intervention compared to people without an eating disorder in similar situations (Ozier & Henry, 2011). It is also critical that dietetic professionals are prepared to provide care for medically complex patients, as the number of patients with diseases that have physical and mental complications is increasing. For example, 75% of amputee patients also suffer from diabetes (Geiss et al., 2019) and in order to serve the patient effectively, professionals should be trained in both areas. Of note, while only 2.86% of participants in this study received education from educators or preceptors with physical or mental disabilities, neurodiversity, and ability is not always visible so the true value is likely higher.

Very low proportions of participants in the study were reportedly educated or trained to interact with people within the LGBQ+ and trans community. Previous research also indicates that the LGBQ+ and Trans community is usually overlooked by accredited dietetics programs and a large majority of RDNs are not trained to interact with people with people in the LGBQ+ and trans community (Douglass et al., 2020; McCabe et al., 2020). One limitation to educating and training dietetic professionals to work with the LGBQ+ and trans community is the lack of research within this community, as most United States nutritional practice research studies about this community are published after 2018, highlighting the limited evidence base available (Arikawa et al., 2020; Douglass et al., 2020; Rahman & Linsenmeyer, 2019; VanKim et al., 2017; Wellington & Bilyk, 2012). The lack of education and resources to serve the LGBQ+ and trans community is likely resulting in an underprepared workforce of dietetic professionals.

Newer ACEND competencies (described above, for adoption in 2022 and published in September 2021, expand on cultural competence, to include addressing bias and developing self-awareness, which are key components of culturally humble care (2022 Standards and Templates, n.d.). However, the proposed competencies are broad and may not lead to consistency in education or training provided to dietetic students. Additionally, ACEND’s current and 2022 standards do not define which type of biases, cultures, or populations RDNs should be trained to serve, which will also likely result in differences in knowledge and preparedness of individual dietetic professionals (2022 Standards and Templates, n.d.; McCabe et al., 2020).

This pilot study used the Diffusion of Innovations (DoI) framework to identify a group of “early adopter” nutrition professionals (persons with a demonstrated interest in improving diversity, equity, and inclusion) to better understand cultural humility preparedness. It is the first study to apply the DoI framework to help understand how cultural humility is taught in dietetics programs and adopted by professionals with an interest in DEI. More research operationalizing the DoI approach is needed to explore cultural humility training in dietetic and other health programs and understand how the adoption of culturally humble care may diffuse through health professions. Due to the use of an unvalidated set of questions, the small sample size for each question (i.e., low number of responses), and reliance on self-reported data, results of this study lack external validity since participants are not representative of the entire nutrition profession. Additionally, the questions rely on self-report and recall bias likely impacts participants’ responses. More research should be done to systematically identify habits and pratices of all adopter categories and their DEI preparedness with the entire population of nutrition professionals.

Conclusion

This pilot study is one of the first to examine self-reported preparedness of dietetics professionals to serve marginalized communities and explore sources of education and training. The results of this study indicate a need for substantial change within nutrition programs (including accredited dietetics curricula) to improve education and training about serving several marginalized communities. Further research should explore characteristics of innovators and early adopters and information about trainings provided or received within and outside of educational settings. Of course, more research is needed about how to best include and serve marginalized populations.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kate G. Burt

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