July 2019 Issue

Diabetes Management & Nutrition Guide: Guest Commentary: Confronting Implicit Bias — The Key to Equitable Diabetes Care and Outcomes
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today’s Dietitian
Vol. 21, No. 7, P. 35

“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe

There’s no question that the United States is becoming more racially and ethnically diverse. The US Census Bureau reports that, by the year 2050, the Asian, Hispanic, and African American populations will increase 212.9%, 187.9%, and 71.3%, respectively, compared with 32.4% for the white population. The prevalence of diabetes in these groups is significant: 12.7% in African Americans, 12.1% in Hispanics, and 8% in Asian Americans, compared with 7.4% in whites.1 Moreover, these growing minority populations are at risk of receiving disparate diabetes health care.

According to the Institute of Medicine, racial and ethnic minorities tend to receive lower-quality health care than nonminorities, even when access-related factors, such as patients’ insurance status and income, are controlled.2 Numerous complex factors contribute to health disparities, but one of the more troubling factors is implicit bias on the part of health care providers. Even when practitioners desire to provide equitable care, they may unintentionally interact with their minority patients less effectively than with nonminority patients.3

Studies show that most health care providers have an implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color. This bias is particularly worrisome when the 2019 demographics from the Commission on Dietetic Registration show that 81% of RDs are white and only 16% identify as belonging to a minority group.

Implicit bias—also known as implicit social cognition—refers to attitudes or stereotypes that affect our understanding, actions, and day-to-day decisions in an unconscious manner. Although it may be difficult to accept, RDs and diabetes educators aren’t immune to unconscious bias. Implicit bias is activated involuntarily and without innate awareness or intentional control. It’s different from the thoughts we might hide for political correctness or explicit bias to which we fully admit. Think of implicit bias as the thoughts you never knew you had. Early life experiences, the media, and news programming contribute to our feelings and attitudes about other people based on characteristics such as race, ethnicity, age, and appearance.4

Although implicit bias is unconscious, there are steps that can be taken to counteract it. The first step is an awareness of one’s views, values, and practices. Discovering biases and beliefs—even prejudices—we may not want to admit to can be emotionally taxing. Yet, experts say that becoming aware of and unsettled by one’s unconscious biases is the first step to addressing them. When we have conscious access to your implicit biases, you can monitor and control them to mitigate their impact on our behavior.5

Georgetown University’s National Center for Cultural Competence suggests using the following probing questions to begin. The questions indicate how bias affects quality of care and contributes to both health and health care disparities. As you contemplate each question, consider factors such as age, race, ethnicity, gender, English language proficiency, socioeconomic status, literacy, or body size.5

• Do my biases do any of the following: impact the amount of time I spend with patients?; influence how I communicate with patients and their families?; hamper my capacity to feel and express empathy toward my patients?; affect the types of treatment and medications I recommend?; or interfere with my capacity to interact positively with my patients and their families?

• Do I ever perceive that I am less comfortable with patients who are of a different race than I am?

• Do I know whether (or believe that) my colleagues and other staff with whom I routinely work think that my attitudes and behaviors demonstrate bias? If so, am I open to discussing these issues with them to elicit their points of view?

• Have patients or their families, directly or through satisfaction surveys, raised concern about my attitude or the way I communicate with them?

As dietitians, we may feel confident in our ability to make objective, inclusive decisions and resist thoughtful exploration of the above questions. However, overconfidence makes it very difficult to correct prejudice or bias. If we don’t have a healthy skepticism for our decision making, we may be unconsciously biased and contributing to the health disparities in the United States.5

Nutrition professionals are required to complete at least one hour of continuing education related to the topic of ethics during each five-year registration cycle. One of the four foundational components of the Academy of Nutrition and Dietetics (the Academy) 2018 Code of Ethics is nonmaleficence. Nonmaleficence means the nutrition professional will cause no harm to individual patients and clients. Notably, harm refers to physical and psychological harm.

Given the Academy’s Code of Ethics, current demographics, and the impact of implicit provider bias on health disparities, I suggest nutrition professionals be required to complete at least one hour of continuing education related to implicit bias during each five-year cycle. I believe implementing this recommendation will maximize the delivery of equitable care and shorten the cultural distance between the RD and his or her clients or patients. Mitigating implicit bias is crucial to optimizing outcomes in diabetes management and reducing health disparities in our growing minority populations.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is chair of the Diabetes Care and Education Dietetic Practice Group of the Academy of Nutrition and Dietetics, and author of the award-winning Diabetes Guide to Enjoying Foods of the World, a convenient guide to help people with diabetes enjoy all the flavors of the world while still following a healthful meal plan.


1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. American Diabetes Association website. http://www.diabetes.org/assets/pdfs/basics/cdc-statistics-report-2017.pdf. Accessed May 10, 2019.

2. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C: National Academies Press; 2003.

3. Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542.

4. Understanding implicit bias. The Ohio State University Kirwan Institute for the Study of Race and Ethnicity website. http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/. Accessed May 14, 2019.

5. Conscious & unconscious biases in health care. Georgetown University National Center for Cultural Competence website. https://nccc.georgetown.edu/bias/module-1/1.php. Accessed May 14, 2019.