February 2021 Issue

Cultural Humility in Food & Nutrition
By Sharon Palmer, MSFS, RDN
Today’s Dietitian
Vol. 23, No. 2, P. 24

Cultural competence within dietetics is encompassing the framework of cultural humility, with careful attention to avoid cultural appropriation and understand the impact of colonization in foodways.

The topic of food within a cultural context is fraught with complexity. At its very core, food is sustenance—a collection of micronutrients, macronutrients, and chemicals. But it’s so much more. The way in which we, as fellow humans, have eaten since the beginning of time has been shaped by numerous factors over the eons, including our tribes, communities, geography, climate, agriculture, traditions, religions, hardships, politics, economics, colonization, and much more.

Civilizations were founded on the simple basis of securing food, and over the centuries multiple influences converged to create the diverse food cultures we see today around the world. From the eating styles of the Sacred Valley in Peru (focused on corn, potatoes, quinoa, and guinea pig) to the food traditions of Morocco (simmered spicy stews cooked in clay tagines and lots of sweet mint-infused green tea) to the traditional diet of Japan (staples including fish, rice, tofu, fermented vegetables, and green tea), the world is filled with glorious eating patterns that have nourished bodies, built communities, and offered joy as people come together to share meals.

As dietitians, we know this firsthand as we work with clients who cherish diverse food cultures and traditions. In the past, much emphasis has been placed on our cultural competence—our ability to understand as well as communicate and interact with people across cultures. That is all good and well, but many dietitians will argue it’s now time to transcend that knowledge to work toward cultural humility, a lifelong learning process that involves continuous self-reflection and self-critique in which we evaluate our core beliefs, values, assumptions, biases, and cultural identities.

Many believe it’s also time to reflect upon the ways in which RDs converse about food and nutrition, considering issues such as colonization and their impact on communities’ diets and health outcomes. Another important consideration is addressing the cultural appropriation of foodways, which describes the act of borrowing certain aspects from a culture other than one’s own without showing acknowledgement or respect for that culture. These reflections come at an important time, given the US population has become more diverse, the current discourse on diversity and civil rights, and the growing familiarity with global foods and traditions.

Today’s Dietitian speaks with several experts in the food culture and the food system to gain insight into how food and nutrition experts can engage in practices that are more culturally respectful, humble, and appropriate.

Moving Beyond Cultural Competency to Cultural Humility
What are some of the primary issues dietitians should keep in mind as they move beyond cultural competency to cultural humility? According to Deanna Belleny, MPH, RDN, cofounder of Diversify Dietetics and a public health practitioner in Hartford, Connecticut, dietitians should keep the following main ideas in mind when expanding from cultural competence to cultural humility:

• Practicing cultural humility is a lifelong process. It’s more than educating yourself on a person’s culture, customs, or food preferences. It requires you to constantly self-reflect, self-critique, and become aware of your own values, culture, beliefs, biases, and position in the world.
• Cultural humility emphasizes that you have something to learn from your clients and patients. Prioritize connecting, listening, and learning in interactions.
• Cultural humility prioritizes respect—respecting your client as an individual; incorporating preferences, culture, and boundaries; and always involving them in any decision making.
• Cultural humility requires historical awareness and educating yourself on historical realities and injustices that shape today.

Denine Rogers, MS, RDN, LD, FAND, chair of the National Organization of Blacks in Dietetics and Nutrition, integrative and functional dietitian nutritionist with a private practice called Living Healthy in Douglasville, Georgia, telemedicine nutritional consultant with Anthem, and cochair of the Anthem e-Commerce Committee of APEX (African-American Professional Exchange), explains that dietitians should understand that cultural humility is a mindset that enables an individual to be open to other peoples’ preferences by demonstrating respectful inquiry and empathy. Cultural competency, on the other hand, is a learning experience about the patterns of behavior, beliefs, language, values, and customs of particular groups. Once we understand other people’s cultures, then we can move on to cultural humility.

That said, cultural humility and cultural competence can exist together, says Alice Figueroa, MPH, RDN, a public health expert, food writer, and founder of AliceinFoodieland.com in New York City. Even if dietitians were trained in a traditional framework that focuses on cultural competence, they can still learn to incorporate aspects of cultural humility into their dietetics practice, Figueroa says. Traditional dietetics programs teach about cultural competence practices that include adopting attitudes, behaviors, and policies that ensure institutions and professionals can respect cultural differences. “Cultural humility asks to evolve beyond cultural competence and embody a lifelong process that requires us to make a commitment to self-evaluation and self-critique about our own biases and prejudices,” Figueroa says.

Cultural Humility in Action
Cultural humility encompasses seeing others as individuals, not as a representative collective of a culture, race, or ethnicity, Rogers says. She suggests dietitians shouldn’t presume to know everything about people’s cultures, beliefs, and practices regarding diet, health, and education. “For one example, do not assume that an African American patient with hereditary coronary artery disease eats soul food when they are a healthy vegan. Ask questions about your patients’ problems to understand better their personal cultural history, experience, and beliefs,” Rogers suggests.

Sherene Chou, MS, RDN, a sustainable food and nutrition consultant in Los Angeles, puts it simply: Instead of a top-down approach, look to the patient as the expert in their culture, life, and practices. See how you can meet their needs to begin building a foundation for a strong, trusting relationship.

Kimberley Greeson, PhD, a researcher on biopolitics of endemic species in Hawaii and professor of sustainability education at Arizona’s Prescott College, adds, “It’s not just about the food, but also the way dietitians approach communities that are not their own. Don’t use a ‘savior’ approach, but be aware that certain communities might have different needs. Be open to different protocols.” Greeson offers the example of immigrants to the United States and the barriers they may face because of policies that make it difficult for them to grow or have access to familiar foods; they may have to travel far to get food that’s healthful, fresh, and culturally appropriate.

“When working with BIPOC [Black, Indigenous, and People of Color] patients, it is important to know that the patients’ views, perceptions, symptoms, culture, and experiences are valid and important,” Figueroa says. “Both client and dietitian must work together and learn from each other to achieve the best health and nutrition outcomes. While a dietitian may have the nutrition science [knowledge] needed to guide and empower the client, the client is an expert when it comes to their personal health history, culture, symptoms, and food preferences. As dietitians, we must listen to our BIPOC patients and learn from their food traditions, nutrition needs, and health goals.”

Being Mindful of Cultural Appropriation
Dietitians also should be mindful of cultural appropriation, which occurs when they take a culturally significant practice from one group (usually marginalized), and turn it into something that benefits another group (typically of higher status), without giving credit, money, or even acknowledgment to the group of origin—ultimately erasing its meaning, Rogers says. From recipe writing to culinary education to cooking videos, there are many opportunities for dietitians to wade into these waters.

Belleny suggests we ask ourselves a series of questions in our areas of practice to avoid cultural appropriation: Is a recipe or food from a culture that isn’t our own? Have we done research to understand its origins? Are we giving credit to those origins? Are we being respectful in how we describe or deliver information? Have we engaged with someone who’s more familiar with this culture than ourselves? Are we the right people to bring this information or create this recipe, or is there an opportunity to amplify someone else’s voice?

Rogers suggests a few more questions: Are we influenced by another culture? Have we given recognition to our influences? Are we claiming others’ work as our own?

Rogers says using the term “ethnic” to refer to immigrant and native food cuisines is a classic example of cultural appropriation, which should be replaced with a greater understanding of cultural food history. Describing a region that’s large and diverse, such as “Asian” or “African,” is another example, Belleny says. Instead, learn more about a food’s history.

Rogers shares an example of one deeper understanding of cultural food history: Slaves in the Caribbean often had to subsist on dried fish because they were denied the opportunity to catch fresh fish; thus, many traditional Caribbean dishes are based on salt cod, such as Jamaican saltfish and ackee.

“Avoid generalizing people, customs, and food names by broad cultural categories,” Chou says. “This assumes that cultures, races, ethnic groups are monoliths without understanding the people or the cultures behind them.”

A specific area to focus on is recipe development. “It’s important to always acknowledge and recognize when recipes are adapted or inspired by BIPOC cultural recipes and food traditions. When a dietitian uses ingredients that are native to a particular culture, it’s essential to learn the history of the ingredients and to share that history with clients and patients,” Figueroa says. She offers an example of creating a chickpea curry with coconut milk that’s inspired by South Indian cooking; it’s important to acknowledge that you were inspired by the food traditions of Kerala, South India. Or when we talk about eating cornbread and squash during the holidays, dietitians can educate about the importance of corn and squash to Native American and Indigenous communities. “We can make sure that people are aware of the crucial role BIPOC communities played in shaping our food system and enriching the foods available for us to eat,” Figueroa says.

Chou adds that in recipe writing and culinary education, dietitians can show cultural appreciation. “[Some] dietitians often eliminate the culture and take their own twist, leaving out critical information that can be a learning and teaching moment. When describing a cultural dish, take time to learn about the history and culture and showcase how foods are traditionally grown, prepared, and consumed. This is an opportunity to celebrate culture.”

Greeson adds, “Don’t pretend you discovered it; instead, shift to expanding on its history and ethnobotany. There are examples of ingredients that people are profiting from without fully understanding [their] cultural sacredness, which minimizes [those ingredients’] significance.”

Greeson stresses that if you know better, you can do better, adding, “Admit that you’ve done cultural appropriation, own it, move on, and learn.” She explains there’s a thin line between cultural appreciation and appropriation. “It comes down to the idea of power—if folks in power of a majority identity are using traditional knowledge of other foods from a marginalized or oppressed community, or ripping it off and not giving credit to it, that’s appropriation. For example, a lot of foods in my Chinese culture are appropriated; Chinese medicine was demonized, but now it’s in vogue and popular in the Western community. Now it’s become acceptable and monetized.”

One way RDs can address the issue is to bring someone in, whether it’s a chef, expert, or BIPOC dietitian, rather than claiming that expertise. “Don’t come across as an expert in a different food culture. It’s great to talk about history and how it’s been modified and what your interpretation is, but refer to experts that have a platform. Pass the mic rather than speak for other people; bring in other voices and highlight them. Use that commodity and capital and share it,” Greeson says.

Decolonizing Foodways
With a greater understanding of food culture and history comes a greater appreciation for how Indigenous food traditions have been altered due to colonization. “Decolonizing foodways is an essential practice because the colonization of Indigenous communities has stripped them of their power and has created a deepening reliance on the government for survival,” Rogers says.

Greeson encourages RDs to look at issues of food sovereignty and ways to reenvision foodways to address issues such as land, culture, and health issues. She adds, “We, as settlers, have forcibly displaced many Indigenous people of this country. In the shifting of the Cherokee from the Southeast to Oklahoma, for example, cultural foods shifted; they couldn’t rely on traditional foods and received foods from the government. For the Navajo, fry bread became popular. In Hawaii, Spam became popular because the government gave it to people to eat. This is an issue about reclaiming a connection to the land; traditional ways of growing food; relationships to food, land access, land health, and ecosystems; and native health, spiritual and mental well-being.”

The first step in decolonizing foodways so dietitians may be more effective at providing support for BIPOC clients, patients, and communities is to acknowledge the impact of colonization, imperialism, and slavery on issues such as food access, malnutrition, food insecurity, and overall health, Figueroa says. She also notes that dietitians may have shortcomings, since their personal and professional experiences—even nutrition research—are influenced by institutions that are a product of colonization.

One way to better understand this concept is to look at the history of the foodways in Indigenous communities. Rodgers shares the story of Native American Indians on reservations. “In 1890, the federal government decided to restrict Native American Indians from leaving their reservations to hunt, fish, or gather local foods—all traditional ways of procuring their food. Instead, they received an allotment of food from the government. These rations were all nutritionally empty foods like sugar, flour, and lard. Over time, processed foods high in sugar and white flour became the norm in Native communities. This one oppressive act altered the future health of all Native Americans. Currently, there’s a surge of learning, teaching, and implementing Native American Indians’ cultural food dishes in some of the reservations in order to reverse the health disparities that continue in these communities.”

This problem can be countered by learning the traditional foodways of Indigenous communities. Figueroa encourages dietitians to make nutrition more culturally humble and take into account the perspectives, stories, recipes, food traditions, eating preferences, and experiences of BIPOC.

Putting It Into Practice
In what areas of dietetics practice should dietitians be particularly mindful of cultural humility? One is the way diverse cultural foods are portrayed. Figueroa suggests dietitians be careful not to portray foods from diverse cultures as “greasy,” “dirty,” or “unhealthy.” Thus, the term “clean eating” can be troublesome in this respect. The idea that we need to take a Chinese, Indian, Ethiopian, Egyptian, Mexican, or Guatemalan recipe and make it “clean” in order for it to be health supportive implies that it’s intrinsically dirty and unhealthful, Figueroa says.

Rogers notes that some may say that soul food dishes are very unhealthful, but if someone learned its history, they would appreciate how African Americans survived with the very little food provided to them during slavery.

In addition, many of the “superfoods” the wellness and nutrition world cherish are Indigenous foods, Figueroa says. “Likewise, the nutrition community should understand that Indigenous and Black communities developed the agricultural, farming, and cooking practices and traditions that make it possible for us to enjoy nutritious foods such as quinoa, cacao, chia seeds, moringa, açaí berries, sacha inchi, maca, amaranth, and lucuma, among others. It’s important for dietitians to be leaders in the food system who seek solutions on how to responsibly and sustainably consume these delicious and nutritious Indigenous foods while honoring and supporting Indigenous communities.”

Even how we consider “healthism” is an opportunity to cultivate cultural humility. “Healthism is essentially the belief that individuals are ultimately responsible for their health, and they should pursue health because it’s the right thing to do,” Belleny says. “The same could be said about what American culture has deemed as a ‘healthy diet.’ The spaces that create these rules are often not diverse and inclusive, from research and academic spaces to media and communications. What is deemed healthy comes with a fair share of bias. As dietitians, let’s be critical of the information we take in. Let’s do more listening and less instructing. Let’s center and uplift the voices and experiences of our clients and patients, and let’s advocate for social justice because there is so much more to health than food and physical activity.”

Greeson adds that dietitians may need to rethink some of what they learned in school, which is based on a Western paradigm of thinking, and that the nutrition models might not accurately reflect genetics among some communities. For instance, Greeson shares the example of being open to traditions in her own Chinese American culture, such as the use of herbs and certain foods. “Look at the complexities of diabetes in minority populations, where policies forced them to relocate and exist on government-rationed food. How can we create pathways to food sovereignty—where people can be in charge of their own food—and how can dietitians work within that framework?”

It’s also important to consider that in some cultures, items such as cheeseburgers, alcohol, and dairy products haven’t been part of the diet for a significant amount of time, another reason to be mindful of genetics.

Rogers also reminds dietitians to be aware of the lack of access to certain foods. People living in urban areas with no full grocery stores (food deserts) may have little or no access to fresh food. Likewise, rural residents in agricultural regions may not be able to afford to buy the same food they can harvest. The experts interviewed provide the following tips for stronger cultural humility in food and nutrition practice:

• Do more to understand historical perspectives related to food and health care.
• Learn about BIPOC food traditions, recipes, cooking, ingredients, and food preferences, and find a way to respectfully incorporate them into nutrition practices and education.
• Do less instructing and more listening to center your patient/student/client’s voice.
• Start engaging in discussions with patients by asking about and identifying their cultural heritage, family values, and beliefs.
• Begin analyzing personal biases and assumptions about patients with different values than yourself.
• Own up to how our privilege enables many of us to truly connect with the patients and communities we serve and find a way to respect their challenges, pain, and struggles and how these factors can impact their health.
• Accept our mistakes, shortcomings, and biases.
• Make learning from BIPOC professionals an essential part of our nutrition philosophy and hear the challenges and concerns they face in the dietetics field.
• Celebrate BIPOC food traditions by sharing the beauty of diverse foodways.
• Develop culturally humble nutrition education materials, making sure the food recommendations are respectful and relevant to BIPOC clients and patients. Create a simple survey to get feedback from the community to learn about their food culture, ask BIPOC clients for recipes their families cook, take part in professional development by BIPOC health professionals, and cook recipes from cookbooks created by BIPOC.

— Sharon Palmer, MSFS, RDN, is a plant-based, sustainable nutrition expert living in Ojai, California. She’s also the nutrition editor of Today’s Dietitian.

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Resources for Cultural Humility and Knowledge

• Oldways traditional diet patterns: oldwayspt.org
• Harvard Implicit Association Test: implicit.harvard.edu/implicit/takeatest.html
• The 5Rs of Cultural Humility: ncbi.nlm.nih.gov/pmc/articles/PMC6445906
• What Is Cultural Humility? Here’s How to Implement It by Maya Feller, MS, RD, CDN: mayafellernutrition.com/2020/06/22/what-is-cultural-humility-heres-how-to-implement-it
• US Department of Health and Human Services Office of Minority Health: minorityhealth.hhs.gov
• Georgetown University National Center for Cultural Competence: nccc.georgetown.edu