Nutrition equity: How to give nutrition advice to diverse families

If nutrition advice were easy to follow, the number of children with type 2 diabetes and obesity would be going down, not up. But as many pediatricians and nutritionists know, food cravings, picky eaters, and hectic schedules pose serious challenges. Add language barriers, a lack of accessible food choices, or food insecurity to the mix, and healthy nutritional habits become even more difficult to sustain.

“In many low-income neighborhoods, fast food is everywhere, but fresh produce is hard to find,” says Carolina Ruiz-Valenzuela, a clinical nutrition specialist at Boston Children’s at Martha Eliot Health Center. Even when they are available, the cost of healthy food options far exceeds many families’ budgets.

“We don’t want to blame parents for conditions they can’t change,” adds Dr. Faye Holder-Niles, a pediatrician in Children’s Hospital Primary Care Center and Medical Director of Community Primary Care. “We need to meet families where they are — then we can help them incorporate healthy eating and exercise into their lives.”

Here Dr. Holder-Niles and Ruiz offer tips for making nutrition advice workable for diverse families.

Build a connection

Nutrition advice can fall flat if a parent feels alienated from the person delivering it. Having grown up in Chile, Ruiz finds many Spanish-speaking families open up to her more easily than if they had to communicate through an interpreter.

“Families feel more comfortable talking with a provider who they feel understands their culture,” she says. “Even within Latino culture, there are many different traditions and cooking styles. Families appreciate it when their provider is familiar with their local food customs.”

Taking time to show interest in how the family lives day to day can elicit a helpful picture of the family’s eating patterns.”

Carolina Ruiz Valenzuela

But what if a provider does not share a language with their patients? Try asking about nutrition in the context of the family’s daily life before giving advice, Ruiz suggests.

“Taking time to show interest in how the family lives day to day can elicit a helpful picture of the family’s eating patterns. Do not assume anything,” she advises.

To understand the context of food in a family’s daily life, Ruiz asks questions like:

• On a typical morning, what does breakfast look like for your family?
• Do you cook that breakfast, or is it pre-made?
• What ingredients do you use?

Find out what meals the family likes to eat

Healthy eating may be more palatable if a family can continue to eat a version of their favorite foods or meals that are important to their culture, says Dr. Holder-Niles.

Before telling a parent what their children can or cannot eat, she asks questions like:

• What meals do you like to cook?
• What food traditions are most important to you as a family?

Then the conversation can naturally turn to possible ways to make a family’s favorite meals healthier. She might suggest using brown rice instead of white rice, for instance, or adding more vegetables. “These are things a parent can do without giving up the foods they enjoy as a family,” she says.

Identify barriers to healthy eating

Depending on where they live, many families have little access to affordable, nutritious foods. Even if they live close to a grocery store, that store may not stock a rich variety of fresh produce.

As an example, Ruiz describes a grocery store near the Martha Eliot clinic. “Their salad bar has chicken nuggets and very few vegetables,” she says. “Families who live in this area have to look harder to find the foods we are telling them to eat.”

Understand that food insecurity may be present, but hard to discuss

In 2020, 10.5 percent of U.S. households experienced food insecurity. Unfortunately, many parents feel ashamed or embarrassed to say they’re struggling to feed their families.

To identify possible food insecurity, physicians at Children’s Hospital Primary Care and Martha Elliot Health Center ask every family standard screening questions.

“Parents are less likely to feel singled out if they know everyone is asked the same questions,” says Dr. Holder-Niles.

If a parent is struggling to cover the cost of food for their family, a Boston Children’s social worker or care coordinator can help connect the families with a local food pantry or other nutritional resources according to their needs. 

Make nutrition advice practical

It’s one thing to tell a parent to feed their children five servings of fruits or vegetables a day.

“It’s more helpful to work with families to understand what that means in a practical way,” says Dr. Holder-Niles.

Many of her conversations with parents cover tangible ways they can ensure their children eat a healthy mix of foods every day. She may suggest replacing snacks with fruit, cheese, or yogurt, blending fruits and vegetables into smoothies, and always adding vegetables to the dinner plate.

“I think very concrete and practical steps help parents see how it’s possible to incorporate the advice we’re giving them,” says Dr. Holder-Niles.

If we really want to help families, we need to appreciate where they’re coming from, embrace their traditions, and help them continue their traditions in a healthy way.”

Dr. Faye Holder-Niles

Most importantly, she and Ruiz never lose sight of the role food can play in a family’s life.

“Food is often an expression of love and cultural connections,” says Dr. Holder-Niles. If parents feel forced to choose between nutrition and expressing their love for their child, many will choose love.

“If we really want to help families, we need to appreciate where they’re coming from, embrace their traditions, and help them continue their traditions in a healthy way.”

Learn more about Children’s Hospital Primary Care Center, Boston Children’s at Martha Eliot Health Center, and Family Food Connections.