29 4.5: Biases in Nutrition Care

Case Study: Anti-Black Racism in Entry-Level Dietetic Practice

Author: Tameika Shaw

In my first year as a dietitian, a 42-year-old client was referred to see me for having a Body Mass Index (BMI) greater than 27 and healthy eating. This client was new to Canada (in Canada 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 7pm 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 or, 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 counseling 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 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 elevated an HbAIC >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.