Although diversity and equity in healthcare has become a hot topic in recent years, experts said action has been slow and not enough is being done in the field of nutrition to address health disparities.
A predominantly white research community and largely white study populations, a lack of diversity among clinicians and leadership, and dietary interventions and recommendations that do not reflect the diversity of the U.S. population continue to be barriers to offering good care for all patients, they said.
“When we don’t have diversity and cultural competency, we end up using cookie-cutter approaches that may not work for every patient,” said Fatima Cody Stanford, MD, MPH, MPA, MBA, an obesity medicine physician scientist and associate professor of medicine and pediatrics at Massachusetts General Hospital and Harvard Medical School, both in Boston.
Disparities in health outcomes abound, according to Dr. Stanford. For example, a literature review she co-authored showed that racial and ethnic minorities with obesity do not experience the same treatment outcomes as their white counterparts (Curr Obes Rep 2018;7[2]:130-138). “A dietary intervention that we think should improve a patient’s health might actually be foreign to them and not lead to the behavioral change we hope it will,” Dr. Stanford said in an interview.
The so-called Mediterranean diet, as an example, is commonly recommended for cardiometabolic health but is based on the eating patterns of “European countries like France and Italy, while the diets of populations of color around the Mediterranean, from countries like Angola, are ignored,” she said. “We risk implicitly telling people that their cultural diets are bad when we recommend a diet from another culture.”
Workforce Equality
With nearly 50% of Black Americans experiencing obesity, “the voices of the profession do not represent the diversity of the patient population they serve,” Dr. Stanford said. A survey she co-authored found that a lack of representation from racial and ethnic minorities among the leadership of professional societies in the field of nutrition, such as the Academy of Nutrition and Dietetics, American Society for Nutrition and Obesity Society (Am J Clin Nutr 2021;114[6]:1869-1872).
Research in nutrition and obesity also needs to be more diverse than is currently the case, Dr. Stanford said. With most studies in the field conducted in largely white populations, extrapolating and applying results to more diverse populations may not be appropriate, she noted.
“Having greater diversity within the clinical trial setting really sets us up to better understand whether we need different types of interventions for racial and ethnic minority populations,” she stressed.
Gender and Sexual Minorities
A better understanding of health outcomes among gender and sexual minorities is also critical to improving nutrition outcomes in these populations, said Nicole VanKim, PhD, MPH, an assistant professor in the School of Public Health and Health Sciences in the Department of Biostatistics and Epidemiology at the University of Massachusetts Amherst.
“There’s lots of room for growth in nutrition research in terms of understanding how dietary interventions apply to those who do not fall into the simple male or female categories, as well as those who have sexual experiences other than exclusively straight,” Dr. VanKim said.
Some of the nutrition-related health disparities among sexual minorities include a 2.1- to 4.1-fold increased risk for obesity among lesbian and bisexual women, compared with heterosexual women, and, as Dr. VanKim’s own research found, a twofold higher risk for type 2 diabetes among lesbian and bisexual women younger than age 40 years and a roughly 30% higher risk among those age 40 to 49 years, compared with their heterosexual counterparts (Diabetes Care 2018;4[17]:1448-1454).
“More work needs to be done as we don’t fully understand why we see these disparities,” Dr. VanKim said. A possible explanation for these relationships is that stigma leads to psychological stress, triggering immune dysregulation and a sustained hypothalamic-pituitary-adrenal axis response. Stigma also contributes to mental illness and unhealthy behaviors such as lack of exercise and eating disorders, placing individuals at greater risk for chronic illness, obesity and cardiovascular disease (Psychol Bull 2009;135[5]:707-730).
Dr. VanKim said existing dietary interventions may or may not be effective for sexual and gender minorities, with findings from the scant body of research pointing to a higher risk for disordered eating in some groups. For example, transgender youth have a higher risk for binge eating, fasting or vomiting, which researchers again have linked to environmental stressors such as harassment and discrimination. Conversely, they concluded that family and school connectedness and social support decreases the likelihood of eating disorders (Int J Eat Disord 2017;50[5]:515-522).
“Dietary interventions might need to be tailored to sexual and gender minorities because people who are marginalized may have more challenges adhering to treatment plans and medical guidance,” Dr. VanKim said. “However, almost all of the research on dietary interventions is among straight and assumed cisgender males and females, so we aren’t able to know what sort of tailoring, if any, is needed.”
Although there are few data on what dietary interventions work and don’t work for sexual and gender minorities, providers can help improve the likelihood of adherence to existing dietary interventions by building trust and creating an inclusive and supportive environment by avoiding assumptions, Dr. VanKim said.
She encouraged healthcare providers to proactively take steps to reduce their own prejudices by using tools such as The Harvard Implicit Association Test, a free online tool to assess bias. “Understanding what our own biases are regarding different groups of people is an important first step toward being able to change how we provide healthcare.”
—David Wild
The experts spoke at the ASPEN 2022 Nutrition Science and Practice Conference in Seattle.
Dr. Stanford reported serving as an advisor or consultant to Boehringer Ingelheim, Calibrate, Currax, Lilly, Gelesis, Good Rx, Novo Nordisk and Pfizer. Dr. VanKim reported no relevant financial disclosures.
This article is from the June 2023 print issue.