🛠️ Chapter 4: Relevance to Practice
32 4.8: Biases in Nutrition Care
Case Study #7
Meet Mr. Campbell
Read the following case study and complete the questions before moving on.
You are a dietitian at a Community Health Centre, and you receive a referral to see Mr. Campbell.
Reason for referral: “Client loves rice and mostly eats West Indian food. Needs help to make healthy choices.”
| Age / Gender | 42-year-old cis-gender male |
|---|---|
| BMI | >27. Client thinks his weight is fine. |
| Medical Hx | Prediabetes (elevated A1C) |
Social Determinants of Health (SDoH)
| Social support | Raising young daughter on his own |
|---|---|
| Housing | Unknown |
| Employment | Shift work |
| Education | Unknown |
| Citizenship | Immigrated to Canada from the Caribbean 5 years ago |
| Language | First language is English |
Diet History
| First meal ( ) | Water |
|---|---|
| Second meal ( ) | Water |
| Third meal (7pm) | A full plate of rice and peas or provisions with stew chicken, stew beef |
| Snacks ( ) | Mostly water |
- Are there any details in the referral that can impact your bias before meeting the patient?
- Take note of their social identities (e.g. age, gender, sexual orientation, education, citizenship, etc.). What are some identities that you do not know and may never know?
- Review your own social identities. List how your identities and experiences offer privileges that may create an imbalance of power, or impact your assumptions, understanding or biases of the patient. Recognize these as areas for curiosity, compassion and empowerment.
- List assessment questions you may have about the patient to better understand their health goals and needs and your capacity to support them.
Going through these questions will enhance your cultural safety skills. With practice, you can work towards developing skills in cultural competence, cultural sensitivity, and then cultural awareness. These more advanced skills will be discussed in Chapter 5.5. You can see the full case study and how Tameika Shaw, a Black RD from Ontario, navigated this real situation, using all four skills, moving beyond basic awareness and competence toward deeper self-reflection and patient-centred care, on the next page.
Case Study: Anti-Black Racism in Entry-Level Dietetic Practice
Author: Tameika Shaw from Ontario
Trigger warning: This case is an example of bias, food insecurity, ignorance, the experience of an immigrant with the healthcare system, food policing, parental buffering and diet culture.
Keywords: Bias, Food Insecurity, Systemic Survival, Parental Buffering
In my first year as a dietitian, a 42-year-old client was referred to me for having a Body Mass Index (BMI) greater than 27 and for healthy eating. This client was new to Canada (in Canada for less than 5 years and raising his daughter without family support). I worked in a multidisciplinary setting, and it was part of our practice to refer everyone to the various allied health professionals for support. Most of the time, the referrals were appropriate and yielded impactful outcomes for the clients in various ways.
However, in this particular referral, there was a note that stated that the client “loved rice” and “ate mostly West Indian food” and needed help to “make healthy choices”.
At my first encounter, the client questioned the reason for referral. He said, “I was told I needed to lose weight.” However, he believed his weight was fine. Since he was already in the appointment with me, I offered to proceed with an intake and dietary assessment, noting that we did not need to focus on weight management as there were other benefits to eating well. The client agreed to proceed and started to answer questions and share his food recall. He was asked about his ability to acquire and prepare food, which he denied having any concerns. In his diet recall, the client revealed that he ate one main meal per day. This meal was eaten at dinner around 7 pm when he came home from work. He described his meals as a full plate of rice and peas or high starch root vegetables like yam, potatoes or chicken, a meat dish. When asked about his reasoning behind eating one meal per day, he said he wasn’t hungry until the evening. Side note: this was 2009, and Intermittent Fasting was not as popularized, so it wasn’t as typical to have one meal.
I provided the counselling and nutrition recommendations as I learned to do. I pulled out the Food Guide as an easy visual graphic, food replica models, and a divided plate to demonstrate the recommendations for food groups, how to eat 3 balanced meals per day with half the plate filled with vegetables, moderate carbohydrates, 1/4 protein, etc. My other advice included: aim to consume brightly coloured fruits and veggies as snacks, eat fish, drink milk, drink water, and move more often. I did not tell him to eliminate his traditional foods, instead shared information on the nutritional benefits of sweet potatoes, pumpkin, yams and how to include them in a balanced plate. He felt relieved that he did not have to completely eliminate these foods from his diet.
The client agreed to return for a follow-up appointment to check in on goals. At the second appointment, the client reported that he was still eating one large meal in the evenings, as he says he isn’t hungry during the day. Since he was only eating once per day, he kept his portions the same.
Then the client disclosed that he wanted to try quinoa instead of rice because he heard it was better for him, but saw that quinoa was expensive when he went grocery shopping.
He then started to talk about his child’s food intake, that he made sure his daughter ate well. He provided breakfast before school, packed her lunch with two juice boxes, snacks and dinner. Based on the description, I asked if he made different meals for his child. He answered yes. He stated that the teacher examined his child’s lunch and would often send notes home if they felt the lunch didn’t meet “standards”. He said, “That’s why I leave the fruits so she can have those in her snacks”. “It’s why I send 2 juice boxes, I make sure my daughter has plenty of “Canadian” food. I don’t want her teacher to contact me”.
By this second appointment, his blood work had been shared by his provider, and it revealed an elevated HbA1C > 6.0%, indicating pre-diabetes.
The client agreed to try some other strategies, like increasing movement and adding a veggie dish of his choosing to his daily intake, as some small steps. He rebooked for the 3rd appointment but did not show up. When he finally came in, he mentioned that he got called in for a shift, so he took it because that was extra income he needed.
Clinical Insight
Parental buffering is the practice of parents shielding their children from the experience of food insecurity, often by restricting their own food intake or skipping meals to ensure their children have enough to eat (Black food insecurity in Canada, n.d.). This survival strategy should not be mistaken or mislabeled or nutritionally diagnosed as a “poor choice” or “poor eating habits”. It would preferably be captured as a sign of food insecurity.
Black Canadians face the highest rates of food insecurity among racialized groups in Canada, with nearly 40% of Black households experiencing inadequate access to food due to financial constraints as of 2022-2023 (Carleton University, 2023; Daily Bread Food Bank, 2021; PROOF, n.d.; Statistics Canada, 2023; University of Saskatchewan, n.d.). The evidence reveals that they are 3.5 times more likely to be food insecure than white Canadians, and that the underlying causes are largely driven by systemic racism and income disparities, with 55% of Black households with a disability reporting food insecurity.
This is an example of how systemic survival exists within the context of food insecurity. Manifesting as adaptive strategies, behaviours, and compromises, individuals and households may adopt to manage chronic or severe food shortages, caused by structural failures in the food system, economic inequality, and inadequate income.
Stop and Reflect
Food insecurity, as demonstrated by parental buffering and food policing, is a concern highlighted in this case study.
- What are the systemic issues and racial discrimination at play, and how did they impact this client’s decision regarding his and his child’s food intake? If you have difficulty identifying the issues, review the case with a friend, family member or colleague to see what you can come up with together.
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Interactive Activity: Food Biases & Cultural Racism Reflection
Our biases and/or lack of knowledge about a group of people can often manifest in our views and understanding of their traditional and cultural eating patterns. This activity prompts you to reflect on whether what you were taught about certain foods negatively impacts how you judge the food and nutrition knowledge and health management behaviours of Black clients and communities. For each food below, select whether you were taught that the food is a healthy choice or a less healthy choice. Then read the explanation to see the evidence behind it. Take time to reflect on what influenced your initial selection and where these foods are from; your reflection may inspire you to learn something new.
Quinoa
Click your answer:
I was taught that this food is healthy
✅ Correct! Quinoa is a seed and a whole grain. First domesticated by the Indigenous peoples around Lake Titicaca and called “chisaya mama”, translated as “mother of all grains” by the Incas. Before global trade expansion, quinoa was mostly included in Peruvian and Bolivian cuisine. What makes it unique compared to some other grains is that it contains all nine essential amino acids, and 1 cup of cooked quinoa provides approximately 8 grams of protein and 5 grams of fibre (Harvard T.H. Chan School of Public Health, n.d.).
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Fried Fish
Click your answer:
I was taught that this food is healthy
✅ Correct (in moderation)! Fish is a source of protein and omega-3 fatty acids even when fried, and health guidance still recommends regular fish consumption (Mozaffarian & Rimm, 2006). Many Afrocaribbean cuisines include fatty fish that are excellent sources of omega-3, including sardines, sprat, mackeral, and anchovies. The fish is often stewed, grilled, steamed or fried. When it is fried, it is frequently not battered, leaving the skin crispy. Although frying can add extra calories and fat compared to grilling or baking, the fish is often a part of a balanced meal including grains, starches, seeds and vegetables.
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Collard Greens
Click your answer:
I was taught that this food is healthy
✅ Correct! One cup of cooked collard greens provides over 500% of your daily vitamin K need, about 25% of your daily calcium, and roughly 5.5 grams of fibre, all for around 60 calories. Traditional cooking methods used by Black Canadians represent traditions from the larger diaspora (e.g., sautéing with onions, tomatoes, herbs, spices, and small amounts of oil) more than the Southern USA preparations that often include a small amount of pork. (Consumer Reports, 2024).
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Grilled Chicken
Click your answer:
I was taught that this food is healthy
✅ Correct! Grilling is one of the oldest food preperation methods and is used in cuisines throughout the entire African diaspora. A 3-ounce serving of grilled chicken provides about 26 grams of protein for roughly 140 calories (Health Canada, 2023).
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Fried Chicken
Click your answer:
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
I was taught that this food is healthy
✅ Correct (in moderation)! Although fried chicken as a recipe is available worldwide, its origins are from Scotland. After settlers brought the tradition to the Southern USA, enslaved Africans modified the recipes with their cooking traditions, making the recipe the popular and global dish that we know and enjoy today (Taste Atlas, 2026). Chicken itself is nutritious, but breading and deep-frying, which are not unique to Black cuisines, adds significant saturated fat and calories, and regular consumption is linked to higher cardiovascular risk (Qin et al., 2021). This is about the cooking method, not the food’s cultural roots — the same chicken grilled or air-fried can be a “healthier” option (see the “Grilled Chicken” card above).
Rice
Click your answer:
I was taught that this food is less healthy
Not quite — try clicking “I was taught this food is healthy” above to see why.
I was taught that this food is healthy
✅ Correct (in moderation)! Rice is an excellent source of energy and a staple in many cultural cuisines. It can be an affordable ingredient, and sometimes a meal to feed picky eaters or a large family on a low budget. It is easily digestible and less likely to contribute to gastrointestinal upset for people recovering from cancer treatment, living with food intolerances or having difficulty with chewing or swallowing. It is versatile and can be used in desserts, porridge, soups, stir-fres or steamed. There are many varieties having differing proportions of starch, fibre, protein and micronutrients. Although white rice has a high glycemic index and less fiber compared to other rice varieties or other whole grains, even people living with diabetes can enjoy it as part of a balanced meal.
Yam
Click your answer:
I was taught that this food is healthy
✅ Correct! It’s important to know that, what the Black Caribbean and African communities call yam (e.g. yellow, white, purple-fleshed tubers) is different than what Black Americans or most non-Black Canadians call yam (i.e. orange sweet potatoes). Yams can be prepared in a variety of ways, including roasting, boiling, steaming, baking or frying. In African and Caribbean cuisine, they are used in a variety of dishes including pone, soups, bammy,fufu or sadza. Black Canadians having enslaved ancestors often refer to yams as a type of ground provision. They are a source fibre, potassium, manganese, and vitamin C, and their resistant starch gives them a low glycemic index, meaning they don’t spike blood sugar the way other starchy foods do (Tareen et al., 2025).
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Roti
Click your answer:
I was taught that this food is healthy
✅ Correct! Roti is a cultural tradition fused into African and Caribbean cuisine from Indian influences. Size, choice of flour and optional filling vary as the recipe travelled across the globe (e.g. Kenyan to Trinidadian cuisines). Varieties like roti, dhal puri, buss up shot, chapati or paratha are used to wrap the main meal or pick up sides such as curried or stewed meat, fish or vegetables, bean stew and chutneys. The dough is a simple water, flour and oil recipe, rolled out and cooked on a hot cooking surface like tawa with little to no oil. Nutrient variety and calories depend on the size of the roti, the type of flour used and what the roti is eaten with.
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Blueberries
Click your answer:
I was taught that this food is healthy
✅ Correct! Native to North America, Indigenous communities harvested blueberries from Canada to Mexico for thousands of years (Leonard, 2019). Blueberries are rich in anthocyanins, antioxidant pigments linked to reduced cardiovascular disease risk and improved blood sugar regulation, while being low in calories and fat (Harvard Health Publishing, 2026).
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Fufu
Click your answer:
I was taught that this food is healthy
✅ Correct! Made from pounded cassava, yam, cornmeal, oats or plantain, fufu, also known as sadza or amala (depending on the country), is low in fat and its resistant starch supports digestive health and steadier blood sugar (Williams-Ngegba et al., 2024).
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Jamaican Patty
Click your answer:
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
I was taught that this food is healthy
✅ Correct (in moderation)! A typical Jamaican beef patty runs 300-440 calories with a significant amount of fat, mostly from the flaky pastry shell; however, Jamaican patties can be filled with ackee and saltfish, callaloo, curry goat or a variety of other traditional Caribbean dishes. Although diets high in saturated fat from pastry-type foods are linked to increased cardiovascular risk (Astrup et al., 2020), Jamaican patties have been an affordable handheld source of protein and energy for children, shift workers and people living on lower incomes for many years.
Okra
Click your answer:
I was taught that this food is healthy
✅ Correct! Okra is a vegetable originating from East Africa. It is used in a variety of dishes including pepper pot soup, egusi soup and Bamya. It is an excellent source of soluble fibre and nutrients like vitamins C and K1, folate, and magnesium. It stands out because its mucilage (the gel-like substance) binds to cholesterol during digestion, helping the body excrete it naturally and support cardiovascular health.
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Callaloo
Click your answer:
I was taught that this food is healthy
✅ Correct! Callaloo is a leafy green originating from West Africa and brought to the Caribbean by enslaved Africans during the transatlantic salve trade (Espisoto, 2019; Proverb, 2019). The actual plant varies between Caribbean islands because enslaved Africans referred to different leafy greens as callaloo based on where they originated from and what was available to them in the new lands they were brought to ( i.e. amaranth or taro leaves). The greens are rich in iron, calcium, vitamin C, and vitamin A. These leafy greens provide robust antioxidant protection and support healthy immune function, showing how cultural green variables stand toe-to-toe with kale or spinach.
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
Fried Plantain
Click your answer:
I was taught that this food is less healthy
❌ Not quite — try clicking “I was taught this food is healthy” above to see why.
I was taught that this food is healthy
✅ Correct (in moderation)! While shallow or deep frying them causes the porous fruit to absorb a high amount of oil, drastically increasing calories and fat, plantains themselves are rich in potassium, fibre, vitamin A, and vitamin C. Depending on how ripe they are, their glycemic index varies. Green and roasted plantains have more resistant starch and have a lower glycemic index than ripe, boiled or fried plantains (Ayodele & Godwin, 2010).
Additional Resources:
Has this activity prompted you to start thinking differently about certain foods? Learn more about cultural racism and how it manifests in nutrition practice by reading Eric Ng’s 2023 paper entitled “Ethnic food practices, health, and cultural racism: Diabetes risk discourse among racialized immigrants in Canada“, published in the Journal of Canadian Food Studies.