The COVID-19 pandemic has magnified severe health disparities along racial and ethnic lines. Black, Latino and Native American populations are more likely to be diagnosed with the novel coronavirus and, after adjusting for age, suffer death rates almost triple or more than that of white Americans.
The reasons for these disproportionate rates of infection are not biological, but rather a result of the impact from conditions in the environments where people live, learn, work and play. Known as “social determinants of health,” these environments influence disease risk more than health behaviors, such as diet, physical activity and smoking, and unfairly expose people of color to increased risk of morbidity and mortality.
According to the Centers for Disease Control and Prevention, Black, Latino and Native American populations are more likely to become infected with COVID-19 because many are essential workers in critical job sectors such as transportation, foodservice and health care. Many live in crowded, sometimes multigenerational, households and are unable to properly social distance. Furthermore, despite suffering higher rates of underlying conditions, such as obesity, hypertension and Type 2 diabetes, minorities may not have access to preventive and curative services due to under-resourced health care facilities, lack of or inadequate health insurance and poor transportation systems.
These disparities in health are not new, and they stem from a lengthy history of structural racism and discriminatory policies and practices in the United States that marginalize specific groups of people. For instance, between 1934 and 1968, banks put a red outline on a map around numerous neighborhoods inhabited by non-white racial and ethnic minorities to indicate areas where they would not finance mortgages. Without cash, people who lived in those areas could not purchase property, and overall home values remained low. With no tax revenue for improvements, schools, hospitals, libraries, parks and other critical neighborhood fixtures, the neighborhoods were poorly funded and there was no incentive for businesses or community infrastructures such as supermarkets. The lack of jobs and underfunding of schools decreased opportunities for advancement and well-paying employment, perpetuating the cycle of poverty.
Likewise, racism plays a role in health disparities. Implicit bias — the unconscious prejudicial attitudes and stereotypes held about social groups of people — impacts the decisions and treatment plans offered by health care professionals. After correcting for access-related factors including insurance status, income and education, minorities are less likely than white people to receive necessary health services and interventions. For example, a 2020 study published in Surgical Endoscopy indicated that despite suffering more obesity-related complications such as kidney failure and diabetes than white men, Black men with severe obesity were less likely to be referred for metabolic bariatric surgery. Reasons cited include implicit bias and stereotyping, such as the assumption that Black males would be less likely to adhere to weight-loss protocols or explore surgical interventions for the treatment of obesity.
When communities are disadvantaged because of implicit bias, structural racism and the social determinants of health, they do not have a fair chance of achieving their best health possible. An equitable environment must be created through economic, environmental and social system changes.
Nutrition and Health Equity (vs. Equality)
Health equity gives all people the opportunity to reach their full health, regardless of race, education, gender identity, sexual orientation, job, neighborhood and whether they have a disability. In contrast to health equality — which distributes the same resources and opportunities to every individual across a population regardless of economic, environmental and societal disadvantages — health equity identifies barriers and allocates the resources required to remove those barriers.
The CDC shared an example of health equity in action: The Bibb County School Nutrition Program in Georgia implemented a standardized menu to ensure all students received nutritious meals. Inequalities existed because some schools did not have the equipment or staff necessary to prepare these foods. To solve this problem and ensure everyone has equitable access to the healthful menu, the nutrition program removed barriers by building a centralized kitchen to prepare and cook some foods.
People with less money, less education and poor living conditions are more likely to experience food insecurity and have a less healthful eating pattern and higher levels of diet-related diseases. The impact of the design and features of their neighborhoods on this burden of disease cannot be ignored. In addition to being food deserts with limited access to a variety of healthful and affordable food, many predominantly Black and Latino neighborhoods lack supporting health infrastructure such as safe, walkable pathways and adequate health care facilities.
Furthermore, many of these food deserts co-exist with food swamps, areas where the ratio of fast-food outlets and convenience stores is greater than supermarkets and grocery stores. Unlike grocery stores, which carry a variety of fruits, vegetables, whole grains and other healthful foods, convenience stores usually offer a higher proportion of high-fat, high-calorie, sugary, salty, ultra-processed foods, often with low nutritional value. When they do carry healthier options, the prices are typically high, variety is poor and quality is low.
Historically, some suggestions for combating food insecurity have included building full-service grocery stores in communities lacking access to fresh, healthful food. However, emerging research shows that while new grocery stores increase access to a wider variety of food, create jobs and decrease transportation costs due to shorter commutes to get groceries, this does not necessarily translate into healthful food choices. Grocery stores and supermarkets continue to market snacks, sweets and other nutrient poor, heavily processed packaged foods. Since most people do not permanently change their purchasing habits simply because there is a new store closer to home, increasing food and nutrition literacy through diet and lifestyle education and the building of fundamental skills such as cooking and meal planning is key to instilling behavior change.
To help close the inequity gap and improve population health, food and nutrition professionals in all practice areas must recognize and respond to health and illness as the result of broad social, political and economic structures. Health practitioners should be committed to advocating for social justice and be willing to have difficult conversations about the impact of racial and social injustices on the health choices and behaviors of patients or clients. It starts at the individual level and intersects with patients, clients, their communities, the institutions that serve them and the policies that govern vital access to services that influence health.
For the individual practitioner: The food and nutrition professional must first acknowledge the presence of structural racism and unpack implicit biases before developing learning and listening plans to mitigate them. This learning is continuous and can be done through self-assessments such as Harvard University’s Implicit Association Test and training programs like the Implicit Bias Training from The EveryONE Project by the American Academy of Family Physicians, as well as utilizing resources such as the extensive library of training materials on StructuralCompetency.org.
Food and nutrition professionals should engage in ongoing dialogue with diverse groups of people, finding common ground and learning from differing opinions. Concurrently, and in addition to developing structural competency, nutrition professionals must practice with cultural humility and acknowledge that a person’s culture can impact not only their food choices, but also their health behaviors. Nutrition care plans should be individualized and avoid monolithic perspectives of what a “healthy plate” looks like. Rather, interventions should include a variety of nutritious heritage foods that are accessible and acceptable to the patient or client.
Beyond increasing food and nutrition literacy, interactions with clients and patients must include screening for food insecurity and other determinants of health. For example, hospitals and clinics can routinely screen patients for food insecurity and partner with local food banks and farmers markets to offer quality produce and groceries in underserved communities at free or affordable cost.
For the Community: Community-based organizations offer people-centric solutions such as community gardens and transportation programs. Stakeholders outside of health care such as faith-based organizations, beauty salons and barber shops have longstanding, trusting relationships and an extensive community reach. With training, these stakeholders can help improve health outcomes. For example, a 2018 clusterrandomized study of Black males with uncontrolled hypertension found that, when coupled with medication management, health promotion by barbers led to a decrease in participants’ blood pressure. In the intervention group, barbers trained to measure blood pressure and encourage follow-up with a pharmacist contributed to a 27.0 mm Hg drop in systolic blood pressure rates. The control group of barbers who only gave instructional information and encouraged follow-up with a health care provider saw a 9.3 mm Hg drop in systolic blood pressure rates.
For Policymakers: Government policies and programs are essential in dismantling health inequities. Food assistance programs such as the National School Lunch Program, Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants and Children improve food security and influence healthy eating patterns by promoting the purchase of nutritious foods and beverages. In 2009 when WIC introduced requirements for the purchase of fruits and vegetables, participants bought 29 percent more fruit and 18 percent more vegetables.
Similarly, subsidies on healthy options such as whole grains and taxes on unhealthful options such as products with added sugars and little or no nutritional value can alter nutrition environments. In Berkeley, Calif., consumption of sugar-sweetened beverages decreased by 21 percent after the introduction of a “sugar tax.” Boulder, Colo., used the revenue from a similar tax to fund health equity initiatives including wellness classes and chronic disease prevention programs.
Lawmakers can enhance the nutrition environment through food labeling laws that guide food reformulations and by implementing controls on marketing of low-nutrient density foods such as cookies, chips and candy in the most common forms of media including television, the internet and team sport sponsorships.
Access to nutrition education is critical for behavior modification and health outcomes. Therefore, food and nutrition professionals should advocate for policies and practices that increase access to nutrition education and counseling such as the Medical Nutrition Therapy Act of 2020, which would expand access to MNT to include treatment of chronic health conditions such as obesity, hypertension, cancer and unintentional weight loss. At present, only diabetes and renal disease are covered for Medicare beneficiaries.
For the Profession: A plethora of studies indicate that a diverse workforce is essential to improving the care of diverse patient populations and that people tend to work in the communities where they are raised. According to the Commission on Dietetic Registration, as of September 8, 81.1 percent of registered dietitian nutritionists are white, 3.9 percent Asian, 3.1 percent Hispanic or Latino, 0.3 percent American Indian or Alaskan Native, 2.6 percent Black or African American and 1.3 percent Native Hawaiian Pacific Islanders. To improve nutrition equity, the profession must increase diversity among practitioners and address obstacles for individuals entering the field.
The conversation has already begun. The Academy’s Board of Directors has empowered the Diversity and Inclusion Committee to make strategic, data-driven recommendations for informing organization-wide initiatives to increase diversity and inclusion in the profession and among leadership. Additionally, organizations such as Diversify Dietetics, Critical Dietetics and Academy member interest groups, including the National Organization of Blacks in Dietetics and Nutrition and Latinos and Hispanics in Dietetics and Nutrition, promote equity by engaging in crucial conversations, mentoring minority students and imparting skills to current and future nutrition and dietetics professionals.
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