Cultural Competence in Nutrition and Dietetics: What We Need to Know

Cultural competence is the willingness and ability to treat a patient effectively and appropriately without the influence of bias, prejudice, or stereotypes (3).

It requires respecting others’ attitudes, beliefs, and values while evaluating your own and becoming comfortable with any differences that arise.

Differences are often seen in race, ethnicity, religion, and food practices.

As a framework developed in the 1980s, cultural competence in the health industry seeks to make healthcare services more acceptable, accessible, relatable, and effective for individuals from diverse backgrounds (1, 2).

In nutrition, it’s a group of strategies meant to address cultural diversity and challenge the cookie-cutter approach to nutrition education and dietary interventions among ethnocultural communities.

This includes nutrition guidelines and illustrations representing diverse food cultures with an expanded definition of “healthy eating.”

It involves nutritionists and dietitians knowledgeable and skilled in cultural counseling techniques including culture in the discussions and recommendations.

They provide unbiased nutrition services that do not undermine culture’s influence on lifestyle, food choices, and eating patterns.

Cultural competence overlaps with cultural sensitivity, awareness, and cultural safety, encompassing more than just race/ethnicity and religion, and it’s careful not to mislabel based on stereotypes (1, 3).

A major aim of cultural competence is to build a system of trained healthcare professionals capable of providing tailored, culturally appropriate expertise (1).

Summary

Cultural competence is a framework developed to make healthcare services more accessible and effective for diverse ethnic communities. It’s a group of strategies that challenge the approach to nutrition education and dietary interventions.

Social determinants of health must be interpreted and understood within the context of systemic racism and how it affects different cultures and ethnicities (3, 4).

These determinants — including socioeconomic status, education, food insecurity, housing, employment, and food access — lead to social gradients and health inequities (1, 4).

These health inequities and subsequent health disparities are amplified among marginalized, red-lined, and underserved populations who may lack access to nutritious foods and food security.

Culture also influences the client’s perspective on health and healing, their use of medication versus alternative therapies, and their food choices and eating patterns.

Models of cultural competence exist and are promoted through nutrition textbooks, practicums, and internships to improve dietitians’ skills related to addressing ethnocultural diversity (5).

However, clinical practice guidelines, meal planning, healthy eating, and medical nutrition therapy are often presented in a decontextualized manner (1).

The encounter between dietitian and patient is shaped by the differences in their cultures, biases, prejudices, and stereotypes (1).

If a dietitian does not effectively manage these differences, a breakdown in trust, communication, and compliance with the nutrition plan may further propagate poor health outcomes.

Dietitians and nutritionists must acknowledge these diverse influences to cultivate an atmosphere of trust and develop an affinity with patients, enabling them to communicate an effective nutrition plan and yield greater compliance and good health outcomes.

Furthermore, healthy eating looks different across ethnocultural communities and geographical locations based on food accessibility, sustainability, and food cultures.

Health disparities may develop if dietitians fail to give culturally competent nutrition interventions.

And while cultural competency is not a panacea for health disparities, more thorough communication with the client promotes better health outcomes (3).

Nutrition advice needs to be responsive, appropriate, and effectively matched to the client’s lifestyle, living conditions, dietary needs, and food culture.

As such, cultural competence is a crucial skill for dietitians and healthcare professionals alike.

Summary

To address health inequities and disparities, the social determinants of health must be understood within the context of culture and reflected through unbiased, culturally appropriate, and respectful nutrition services.

Below are some real-life scenarios that observe the breakdown in communication that cultural barriers can cause due to inadequate or inappropriate cultural competence.

While reviewing these scenarios, you can consider solutions that could improve the outcome of similar future events.

Indian patient versus dhal

An Indian patient with a high-risk pregnancy and prediabetes struggles to make the appropriate dietary changes to support her blood sugar management.

Her comfort food is dhal (puréed split pea soup) made by her mother.

At her third visit, the visibly irritated dietitian reiterates that the patient simply needs to stop eating too many carb-rich foods and ends the consultation.

Islamic patient and calorie count

The patient, who is recovering from a stroke, could not communicate directly with the healthcare team.

The hospital’s menu contained items unfamiliar to the patient, and his relative prepared cultural foods for his consumption.

The dietitian couldn’t find comparable ingredients in the institutional nutrient analysis software, and the calorie count was foregone — using Ensure supplement intake to estimate overall intake.

Nigerian client and cornmeal

Unfamiliar with cornmeal — ground maize — the dietitian did not understand the composition of the client’s meals and how to provide culturally appropriate recommendations.

The client also struggled to describe her dishes, which used starches not commonly found in the American diet.

This and the previous scenarios represent challenges with cultural competence, communication, and trust across interpersonal and institutional levels.

Summary

A lack of cultural competence creates a barrier to effective communication. These are missed opportunities to provide appropriate nutrition interventions tailored to the patient’s dietary and health needs.

Change is required at both institutional and individual levels — and there’s evidence that this reduces health disparities (1).

At the individual level

Performing a self-assessment of your own beliefs, values, biases, prejudices, and stereotypes is the first step to becoming culturally competent (3).

Be cognizant of what you bring to the table — both positive and negative biases — and become comfortable with the differences that may arise between you and someone from a different ethnocultural background.

People do not need to be the same to be respected.

Here’s a list to help you get started:

• Address your personal biases and prejudices by reflecting on your own belief system.
• Acknowledge the differences that your clients may have, but do not pass judgment, remaining neutral instead.
• Ask permission instead of lecturing the patient. Asking, “Do you mind if we spoke about [insert cultural topic/behavior]” communicates respect for the patient, and they are more likely to be engaged.
• Develop culturally appropriate interventions that are specific to the patient and not a stereotype of their ethnicity.

At the institutional level

The forms of help that are available in a healthcare system reflect the value it places on cultural knowledge and practices (1, 2).

The inability to access culturally appropriate nutrition and dietary services is a form of social inequity and health disparity.

Institutions can seek to improve how they engage with and empower members of marginalized communities (1).

Here are some suggestions for improving cultural competence at the institutional level:

• Hire a diverse staff that’s representative of the ethnocultural diversity of the patient population.
• Ethnic matching of dietitian and patient may help the patient feel safe and understood.
• Create standards of practice that encourage dietitians to develop culturally adapted interventions or offer patients interventions drawn from their own cultural tradition as part of the care plan.
• Possibly refer to other sources of healing that are safe and align with the patient’s cultural practices.
• Include nutrition guidelines that consider food cultures, including one-pot meals, as these are a part of several immigrant and ethnocultural dietary patterns.

Summary

Change is required at both individual and institutional levels to build culturally competent nutritionists and dietitians and a supportive healthcare environment capable of reducing health disparities.

Some literature suggests that cultural competence is insufficient — that simply making nutritionists and dietitians aware of cultural differences is not enough to stop stereotyping and affect change (1).

Furthermore, some cultural competence movements may be purely cosmetic or superficial.

The concepts of cultural safety and cultural humility have been proposed as more inclusive and systematic approaches to dismantling institutional discrimination (1).

Cultural safety looks beyond an individual dietitian’s skills to create a work environment that’s a safe cultural space for the patient, one that’s sensitive and responsive to their various belief systems (1).

Meanwhile, cultural humility is viewed as a more reflexive approach, going beyond just acquiring knowledge and involves an ongoing self-exploration and self-critique process, combined with a willingness to learn from others (6).

To demean or disempower a patient’s cultural identity is considered a culturally unsafe practice (7).

However, although some patients may feel safe and understood concerning institutional cultural competence and ethnic matching of dietitian and patient, others may feel singled out and exposed to racial prejudice (1).

Implementation of cultural competence in clinical practice may also extend consultation times, as it requires more dialogue with the patient.

Interestingly, not every non-Western practice is going to be the best intervention.

It’s essential to move away from the notion that any one style of eating is bad — the way Western eating has been demonized — to addressing eating patterns that may be harmful regardless of origin.

Summary

There are downsides to cultural competence that create further challenges to institutionalizing it, including cosmetic movements, lack of inclusivity, and unintentional prejudice.

Within the Academy of Nutrition and Dietetics (AND) and independent organizations, several Member Interest Groups advocate diversifying nutrition to make it inclusive. These include:

• The National Organization of Blacks in Dietetics (NOBIDAN). This professional association provides a forum for the professional development and support of dietetics, optimal nutrition, and well-being for the general public, especially those of African descent.
• Latinos and Hispanics in Dietetics and Nutrition (LAHIDAN). Their mission is to empower members to be food and nutrition leaders for Latinos and Hispanics.
• The Asian American and Pacific Islanders (AAPI) and Indians in Nutrition and Dietetics (IND). Their main values are advocating for cultural topics and cultural approaches in nutrition and dietetics.
• Diversify Dietetics (DD). They aim to increase racial and ethnic diversity in nutrition by empowering nutrition leaders of color and assisting aspiring dietitians of color with financial aid and internship applications.
• Dietitians for food justice. This Canadian network of dietitians, dietetic interns, and students addresses food injustices. Members work to create an anti-racist and health equity approach to food access in Toronto and beyond.
• Growing Resilience in the South (GRITS). A nonprofit bridging the gap between nutrition and culture by providing free nutrition counseling to vulnerable populations and programs for dietitians and students to improve their understanding of African American cultural foods.

Summary

Member Interest Groups and other non-academy organizations are pivoting dietitians’ roles as advocates of cultural competence in dietetics and food access.

Cultural competence is the willingness and ability to provide unbiased, judgment-free nutrition services to people and clients of diverse cultural backgrounds.

Cultural competence and cultural safety intersect and demand institutional changes to facilitate the forms of help available to minority and marginalized communities.

However, culture is a fluid concept, and nutritionists and dietitians must not assume that every member of a specific ethnic group identifies and complies with that group’s commonly known cultural practices. They may have adapted their own values and practices.

Dietitians should remain impartial and engage clients in meaningful conversations that will equip them with the information they need to provide culturally appropriate, respectful guidance.