Diversifying Dietetics Is Going to Require White-Lady Discomfort

And centering the voices of Black students, interns & dietitians. Can we do it?

Dietitian in a hospital kitchen // The National Library of Medicine

When I stumbled into the field of dietetics in my 30s, I had no real idea what lay ahead for me. I didn't realize all the free labor that would be required, both directly and indirectly, or that I would have to pay to be an unpaid full-time dietetic intern for nine months, or that the median salary would be rather dismal when I finally finished my schooling and costly internship.

And as I talked about with Laura Thomas on her podcast, Can I Have Another Snack?, I started my journey in Southern California, in a program that was unusually diverse, as far as dietetics programs go. Intellectually I knew that dietetics was a field of mostly white women, but I didn't experience it spiritually until later. In California, we all seemed to be in the same boat, trying to survive O-chem while juggling part-time jobs and the volunteer work we needed to do so we could "stand out" when it was time to apply for dietetic internships.

09: Nourishing Anti-Racism Work with Anjali Prasertong

But boats in America aren't all built the same.

The Academy of Nutrition and Dietetics (AND or the Academy) and the Commission on Dietetic Registration (CDR) know that it is a problem that 80 percent of registered dietitians (RDs) in the United States are white, 93 percent are women, and the percentages of Black and Latine RDs are far lower than the demographics of the country as a whole. (More statistics can be found on my About page.) They have tried to address it in their way—providing toolkits, member interest groups based on racial/ethnic affinity, and diversity promotion grants which modestly fund initiatives to increase interest in the profession among underrepresented populations—but none have tackled the larger systemic and institutional barriers that makes it more difficult for BIPOC individuals to enter and excel in the field. 

Perhaps most importantly, AND and CDR have not publicly acknowledged the role of dietetics in perpetuating racism and inadvertently or intentionally causing harm to BIPOC communities since the field’s inception in the early 20th century, or demonstrated a willingness to examine and overhaul their own processes in order to make them more equitable. If you search for "racism" on AND's professional website, eatrightpro.org, there are four results. FOUR.¹ And two of them are statements from June 2020. 

If you are looking for self-reflection and an apology, you won't find it in the June 2, 2020 message from the president at the time, Linda T. Farr, which begins with:

The Academy of Nutrition and Dietetics believes American society, leaders and organizations must commit to doing more to address systemic racism and pervasive inequities across all facets of society, and is developing an organizational stance that will address social injustice and its effects on public health. Our commitment to diversity and inclusion are the cornerstone of the vision of the Academy of Nutrition and Dietetics, a world where all people thrive through the transformative power of food and nutrition.

The vague language around accountability ("organizations must commit to doing more") and the fact that they needed more time to "develop" their stance on the murder of Black people at the hands of law enforcement (really?) have always angered me, but I just noticed that she didn't include equity as a cornerstone. Therein lies the problem. 

To become a registered dietitian, you need to complete a bachelor's degree, nutrition-specific coursework that is heavy on the sciences (as part of a degree program or completed separately), a supervised dietetic internship (DI) that covers a minimum of 1200 hours, and beginning in 2024, a masters degree. There are not enough internships for every student who wants one; in 2021, nearly 30 percent of applicants did not match to a DI. Most internships are unpaid, and many require that interns pay, often via tuition to the school the internship is affiliated with. My alma mater Tulane University charges $9,000, which is solidly average, according to a database from All Access Dietetics—but you don't get a degree out of it, so it's not exactly a steal. On the high end, the Boston University/Sargent College program costs $63,185 per year, and requires 16 months. You get an MS degree, but still.

This is probably a good time to mention that the median salary for RDs, according to US News & World Report, was $63,090 in 2020. The math is grim.

And cost is a huge barrier for many students, but particularly for BIPOC students who are much less likely to have access to generational wealth. A 2019 study found that the median net worth for white families was $184,000. For Black families it was $23,000. (See chart below.) For Black households in particular, these disparities are directly related to decades of racist policy practices, such as redlining.

Source: U.S. Department of the Treasury

Hey! I can hear a white dietitian or nutrition student saying. I know plenty of poor white nutrition students. Or I didn't get any money from my family. But wealth can support the next generation beyond direct cash gifts. If your family provides you with a car², if you can live rent-free with a relative who has extra space, or if you have the freedom to not contribute financially to your family because they don't need your income to survive—these are all privileges that are less available to BIPOC families, especially Black families, due to systemic racism. (But also, yes! The staggering cost of the internship plus the new masters requirement sucks for everyone, full stop.)

These factors are reflected in the descriptively-named paper "Systemic and Institutionalized Racism, Not Achievement Gap Factors, Limit the Success Of Black, Indigenous, and People of Color in Dietetics Education and Credentialing," in which registered dietitian Kate Gardner Burt and her fellow researchers found that Black dietetic students and interns more frequently reported working full-time and volunteering fewer hours than white respondents and other respondents of color. (Volunteering is highly prized on dietetic internship applications.) BIPOC participants less frequently reported using family savings, and more frequently reported utilizing aid such as SNAP and Medicaid. They found no significant differences between racial groups in academic measures, however.

That  White  participants  and  BIPOC  scored  similarly  on  all  scales  related  to  academic  attitudes  and  skills  (academic  confidence,  mentoring,  time  management,  grit)  indicates  that  there  are  no  disparities  on  factors  known  to  fall,  in  other  majors  and  fields,  along  racial/ethnic lines.

And yet they also found that despite their academic similarities, BIPOC participants overall reported lower rates of planning to apply or applying to DI programs than white participants, with a startlingly low rate among Black participants. Just 48 percent, meaning that over half of Black participants decided to stop their dietetics journey before applying for a dietetic internship. Only about 10 percent of white participants did the same.

Why the cliff? And more importantly, why aren't we laser-focused on answering this question? If diversifying the field is a "cornerstone" of the Academy's mission, why aren't we centering the voices and experiences of Black nutrition students, interns, and dietitians, who are most affected by systemic barriers and personal biases in the profession? Not in a performative gesture of supposed change, but with real intention and empowerment—and probably a lot of white-lady discomfort? (That's a large part of why, I suspect.)

This week I watched Trevor Noah's thank-you to the Black women who have shaped him and taught him throughout his life. And like

Roxane Gay

, who wrote about the segment in her newsletter, I haven't been able to stop thinking about it. She says:

I am so moved and can’t stop thinking about it, not for ego reasons though yes, it is nice to be named, but because it is so rare that people acknowledge Black women, both in terms of the cultural burdens we bear, but also in terms of the expertises we offer. When people do talk about Black women, it’s either with derision or insult or it’s infantilizing or a pithy slogan like “Black women will save the world” or “Black girl magic,” without any specificity.

"Unlike everyone else, Black women can't afford to fuck around and find out," Noah says in the segment. "Black women in particular, they know what shit is. Genuinely." 

Dietetics is not a safe space to share your truth as a BIPOC person. Without an institutional pivot toward admitting mistakes or doing the uncomfortable work required for meaningful change, there is no motivation for BIPOC students, interns, and dietitians to be real; there is only the threat of professional and personal blowback. (As I said to my husband while working on this piece, "Hopefully this won't come back to haunt me!" Is this a good time to remind you that becoming a paid subscriber helps me continue this work?)

I'm grateful for the seven African American dietitians who anonymously shared their experiences with Jennifer L. Warren in her 2017 dissertation, a rare qualitative study about the experiences of BIPOC dietitians.³ When participants were asked about the impending master's degree requirement and the future of the field, Warren notes:

A sense of hopelessness (code theme HOPELESS) appeared during the coding of this data. The idea that the profession, an overwhelmingly white association, was in control and had made up their minds, and nothing else could be done. Marilyn says, “…there is no incentive for a primarily Caucasian organization to reach out to African Americans. I don't see why they would be that concerned.” Similarly, from Sylvia, “Is it a good idea? We don't have a choice. I think it's going to hurt a lot of people.” Similarly, Thea replies, "I love my profession, but it's not being responsive, there are so few African Americans in the profession and we won't be having any more. The diversity will be reduced. We won't be able to serve our clients well. We need the members to raise up. The ones who know are just trying to survive.”

Code theme HOPELESS sums up my feelings about dietetics some days.

Will the members raise up? I don't know. Will those who have the power to change the path to becoming a dietitian listen to Black dietitians and other marginalized students, interns, and dietitians when we tell them what we and our communities need to thrive in this field? I'm here, writing this, so I suppose I keep hoping. Against all odds, I can't give up on the possibility of change.

Shout out to the Black-led nonprofit organization Diversify Dietetics, which has done so much over the last several years to amplify the voices of BIPOC dietitians and support BIPOC nutrition students and interns. If you are looking for a good cause to support, check out their Fund the Future campaign.

1. For comparison, I did a search for "racism" on the website of the American Public Health Association and there were 18 pages of search results, and nearly 400 results total.

2. There are also racial disparities in car ownership. Most DI programs require access to a car—or a lot of money spent on rideshares—as you work at a variety of locations, often in a large geographic area.

3. Warren turned her dissertation into a published paper: Diversity in Dietetics Matters: Experiences of Minority Female Registered Dietitians in Their Route to Practice.