Shireen: Dr. Alison Brown talks to us about her research in cultural nutrition and racial and ethnic health disparities.

Podcasting from Dallas, Texas, I am Shireen. And this is the Yumlish Podcast.

Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.

Dr. Alison Brown is a public health nutrition researcher committed to addressing diet related health disparities, and currently serves as a program director at the National Heart Lung Blood Institute. She's the past chair of the National Organization of Blacks and Dietetics and Nutrition and a past American Society of Nutrition Science Policy fellow.

Welcome Dr. Brown.

Alison: Thank you, Shireen. Happy to be here.

Shireen: Absolute pleasure having you on. So, Dr. Brown, can you talk to us a bit about how you realize your passion for nutrition and specifically your work in culturally informed nutrition?

Alison: Yeah, happy to. And it, it really stems from early childhood and witnessing many family members of mine struggle with not only their weight, but other diet related diseases.

Um, and I specifically had an uncle. He was my favorite uncle, uncle Dan, and unfortunately, he died from a massive stroke, uh, due to his uncontrolled hypertension, um, at a very early age, at the age of 47, it really sent a ripple effect and devastating impacts on the lives of children, as well as his wife.

And I just saw that and witnessed that firsthand. Uh, so that was kind of the initial phases. And I'd always been interested in nutrition. I was an athlete in college and, uh, throughout my early life. But at that stage, I was interested in medicine. And, um, after I graduated, I completed an internship in The Gambia in West Africa, and this really solidified my interest in pursuing a career in nutrition.

And it allowed me to witness the spectrum of diseases caused by nutrition. So, on one end you have issues of under nutrition and malnutrition. Due to not getting enough nutrients. And then on the other, you had issues of overnutrition and the noncommunicable diseases that we experienced in the US and other nations across the globe, really. So, including heart disease, hypertension, high cholesterol, type two diabetes, uh, you name it. So, after this internship experience in West Africa, I enrolled in a nutrition program at Columbia School of Education. With the goal of focusing on community education around the importance of proper nutrition and really tailoring your messaging to appropriate audiences.

And then also my passion for culturally informed nutrition programming, uh, really stems from my bi-cultural upbringing. So, my mom is African American born in Michigan. So, the Northern Black experience, if you will, is quite different than the experience of a Black African American, um, in the south, in, in California, and so forth. And then my dad is from the Caribbean Island of Trinidad and Tobago. So having that bicultural experience is seeing the differences on a food patterns between the two sides of my family, as well as the differences in diet related diseases, honestly, between the two groups of my family really helped solidify my interest in kind of the cultural importance or the importance of culture and shaping someone's diet and what they eat.

Um, and then related to this as the importance of considering the diversity of cultures that exists within specific racial and ethnic groups. So, I mentioned kind of cultural differences of African Americans in the United States, based on where you settled in the, in the country. And really Blacks in the US are not a monolith, um, with one sole identity.

And again, it's a very diverse, which requires to be kind of understanding of this when you're developing nutrition programming. So, for example, the diet you recommend for a Black person from Mississippi would be different from the diet that you recommend for an immigrant or even the child of an immigrant say from Nigeria, Ethiopia, or Haiti, for example.

So really needing to consider that diversity. And I'm speaking from my experience growing up as a Black woman in America, but that plays into any racial and ethnic group, whether that be your Southeast Asian or from Latin America or from West Africa and so forth. So, all of that really plays a role into what you eat and why you eat it and kind of that cultural relevance that you have for that.

Shireen: I appreciate that you mentioned culture relevance just now, help us understand what is the difference between cultural competence and then cultural humility?

Alison: Yeah, I'm glad you raised that point because cultural competency, um, you know, it's often used in kind of the dietetic training profession and even healthcare professionals overall.

And then there's a relatively newer term called culture humility. And while they're similar, I really identify more with the cultural humility term. Cause unlike cultural competency, cultural humility is this lifelong process of really having this openness to another person's, uh, culture. Uh, whereas cultural competency, even including that word, competence or competency makes you feel like you could become fully competent in another person's class.

When, you know, we all know the diversity in different cultures is nearly impossible to be competent in another person's culture. So again, this idea of cultural humility is to be open, to understanding another person's experiences, not making judgements or, you know, assuming anything about them, but really being a person centered and really starting from their vantage point and what their cultural background is.

So again, I think it's important that we have kind of that stance around understanding someone's cultural background.

Shireen: I appreciate that. And then how much of your work really is focused on communities of color and tell us more of what that looks like?

Alison: Yeah, happy to, and, you know, as an African-American woman, I've always had an interest in focusing on communities of color, you know, and these communities, particularly African Americans and Blacks in the US have high rates of diet related diseases. So, when you look across the board of different disease rates, hypertension, type two diabetes, obesity, cardiovascular disease, all of these are kind of off the charts when it comes to the Black and African American population. So that really, again, kind of that motivation and my experience in this space is really doing community-based nutrition education in various communities based on the different cities that I've lived in.

So, whether that be New York city or Boston, um, and just to elevate a program that I created in Boston, and it was called the Keeping It Real program. I mean, it targeted women who attended an all-women’s gym in the Dorchester community of Boston, which is predominantly African American, uh, very diverse, rich communities of different ethnic backgrounds.

So, there's a large Cape Verdean population, Jamaican, Trinidadian, a very rich and kind of the Caribbean culture as well. So, you know, I developed that nutrition program. And then in terms of research, my work also particularly focuses on the African American population. So, I served as a research manager for a study targeting cardiovascular disease prevention among African American women.

Um, and that the key thing about this intervention is the curriculum was unique in that it used the civic engagement approach to train study participants to be change agents within their community. And, you know, I really have to honor and appreciate the work and inspiration by my mentor, Dr. Sarah Folta, who's the lead PI on that research study. And the whole goal is that once training these women, because it was a woman-based intervention, training them to be change agents within their community, would in turn lead them to be more self-motivated intrinsically motivated to change their own diets and physical activity behaviors.

So that's one aspect of my experience. And then another, uh, for my doctoral training, I looked at the diversity in the US Black population and how this relates to diet quality, as well as differences in risk for high blood pressure. That was limited based on the dataset that I used on comparing us born Blacks versus foreign-born Blacks.

But as I mentioned, there's heterogeneity within both of those subgroups, but the research findings showed that foreign born Blacks are more likely to have better diet, quality and lower risk for hypertension than their US born counterparts. And then this quantitative data was combined with some qualitative research that demonstrated the barriers and facilitators of Black immigrants and how they adhere to their cultural diets. So, it had a lot of rich storytelling. If you will, of the participants, they really talked about how they try to adhere to their cultural diets, uh, the challenges that they face. So, whether that be commuting far distances to get the culturally appropriate ingredients, but they also had different adaptive strategies that they use.

So, when they would travel back to their home country, they would bring spices and different foods with them back in their luggage, if they could, you know, and they were checking their bags. So, there were different adaptive strategies that they used, or I remember there was a participant from Ethiopia that talked about teff that injera bread is made out of and how they had to, because teff was much more expensive in Boston that they would adapt their recipes to include more wheat, like half wheat, half Chet.

That's just another example of how, you know, socioeconomics played a role into it and how they really had to adapt their strategies based on where they lived in migrating to the United States. And then lastly, my current role as a program director at the NIHBI, National Heart Lung and Blood Institute, I really helped support researchers doing research in this space.

So, I manage a portfolio of grants that include interventions as well as observational studies that target minority communities, but through the lens of nutrition and nutrition health disparities research.

Shireen: You mentioned a community and also socioeconomic, what is the role of community and social determinants of health in particular and really in the creation and success of cultural nutrition programs?

Alison: Yeah. I'm glad you brought that question up and, you know, I think it's really important to look at when working in diverse communities of different cultural backgrounds to really look at the participants' needs and what they really need to really adapt their diets. And I call that and people in the research community call that, people are person centric approaches.

So, I think the key is starting off with a needs assessment and asking community members directly what they want to learn in a nutrition program. And that's a really a key starting point as well as asking key questions. So, a sample question could be, what do you currently typically eat? How often do you go to the grocery store?

How often do you eat out? What cultural background are you from? So, starting from the participants first, and those who will be attending your program and really understanding their baseline is a key starting point. And then related to that, uh, you know, that's specific to what they're eating, but you really have to move beyond someone's cultural background and really start to understand their social circumstances and the social determinants of health.

And I really liked the framework that Healthy People, 2030, put around the social determinants of health, it includes educational access and quality, economic stability. Neighborhoods and built environment, a social and community context. Then lastly, healthcare access and quality, and several of you guys listening to this, if you're in the public health space, that wouldn't be necessarily new to you, but it's really important to consider these factors when developing nutrition programming.

Uh, and so that at least some of the questions that could be asked in the formative phases of developing a program is what are socioeconomic status is of those who are participating in the program? What's their current knowledge base in terms of access, do they have access to affordable produce in their communities?

Is it affordable? Um, you know, really starting and understanding where your participants are is a key starting point and at the thing, or do they live in a food desert? If it's riddled with fast food restaurants and corner stores, that's going to be a, you're going to use a different approach as compared to someone who lives in the suburbs.

So, you really want to understand your participant also, do they have access to a car? Do they take public transportation? All that will play a role into the strategies that you recommend in your programming. And again, all of these aspects of a person's life should be considered in developing these culturally and socially relevant nutrition programs.

And oftentimes people just scratch the surface and, uh, just think of someone's culture, but it's also those social elements of a person's identity and experiences and lived experiences. It should be considered. And another aspect is research. So, you know, there's, you know, one component is tailoring a program on the ground and community, but another is the research.

So thought that it would be important to include that here as well. And that's called community engaged research, and it's really engaging community members all throughout the research development process from identifying your research question, designing and developing the intervention itself, including the study design, and data analysis and then disseminating the information after you find your results of your study. And it really, it's important to engage community members in all steps of the research development process. In December of last year, NHLBI held a workshop it's called the Sanders Walk-ins Virtual World. And it focused on building trust and community engaged research.

Um, I really highlighted the importance of truthfulness and transparency as well as trustworthiness in the biomedical research enterprise, because when looking at working in diverse communities and thinking about reasons of historical distrust, you know, because of experiments, such as the Tuskegee experiment and other issues around the research process, you know, that distrust is very much warranted.

It shouldn't be surprising. So, with that in mind, you know, what can researchers do to help build trust considering that history and again, engaging community members, seeing the assets and strengths within communities and building on that to identify research questions and develop the research process is really key in building trust and ultimately addressing health disparities.

And although this isn't specific to nutrition, you know, in any type of intervention development process related to nutrition, you know, community engaged approach should be taken.

Shireen: In just a minute, uh, Dr. Brown, can you speak to research related to cardiovascular disease and cultural appropriateness of diets and specifically referring to the DASH diet or Mediterranean diet? You can briefly explain that.

 Alison: Yeah. Yeah. And I'm glad you mentioned that because these are the two main diets that have been shown to help manage and prevent cardiovascular disease. So, DASH diet is short for the Dietary Approaches to Stop Hypertension. And then many of us are familiar with the Mediterranean diet.

Uh, but the DASH side is one rich in vegetables and fruits and whole grains. It also includes fat free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils. So those are things you can eat, but it also recommends to limit foods that are high in saturated fats, such as fatty meats. And so forth.

And then lowering intake of sugar, sweetened beverages and sweets, as well as your sodium and NHLBI provides a lot of different culturally appropriate recipes that are heart healthy in order to adhere to the DASH diet. And they're tailored specifically for the Hispanic population, African Americans, American Indians, and Alaska natives, as well as Vietnamese and the Filipino community.

So would highly recommend your listeners to go on NHLBI’s website to look at those resources. And the Mediterranean diet is similar to the dash diet and that it's emphasizes fruit and vegetables and whole grains, but it also has a greater emphasis on fatty fish, as well as moderate amounts of red wine.

And then the use of olive oil as well, which is indigenous to the Mediterranean region. But in terms of next steps for research, there really is a need for implementation science research on culturally adapting, these dietary approaches to those of different backgrounds. So, when someone thinks about the Mediterranean diet, they think of a very Euro European Eurocentric standpoint, but it could be where other cultural diets could be adapted for those cultural backgrounds and those around the world, based on what the what's indigenous to those regions. So, it's really important that more research looks at this and also looks at what are some of the barriers and facilitators of the uptake of these diets in minority communities. But again, it really is beyond the cultural element of it, but more about the social circumstances that really shape what someone has access to, what they can afford.

All of those are really key drivers of the diet related disparities that we see and should be tackled.

Shireen: Um, just in the last minute here, recent work really focuses on the root causes of racial and ethnic health disparities. How did you really even uncover the need for this kind of research? And can you also speak to what solutions do you hope to see as a result of yours and others research in this area?

Alison: Yeah. Excellent question. And it really, the root causes of diet related health disparities are very complex, and someone's diet is based not only on their culture or the knowledge of what they think is appropriate to eat and what's appropriate not to eat, but it's really those systemic factors like income, how much someone's making, where they live, the foods that are available in their communities that we really need to tackle.

And when I say that health disparities are complex problems. Complex problems require complex solutions. So, with that in mind, it's really important to think about multi-level nutrition interventions, where you can intervene on these multiple levels of what's known as associate ecological model, and really go in well beyond individual level interventions.

But those that look at the interpersonal level, the community level, the built environment and the neighborhood as well as societal level factors. So really intervening in multiple levels is going to be key to helping address these diet related disparities.

Shireen: And with Dr. Brown, unfortunately we're toward the end of this episode.

Um, how can our listeners really connect with you and learn more about your work?

Alison: Yeah, I would be happy to answer any follow-up questions. I can be reached on LinkedIn, and I often post about nutrition and health disparities related topics and events. So, feel free to reach out.

Shireen: That sounds great. Thank you so much, Dr. Brown. And to our listeners over to our Facebook, Instagram after this episode and answer this question: What role does community play in your nutrition choices? So, head over to our Facebook or the Instagram page and answer this quick question for the podcast, which is: what role does community play in your nutrition choices?

We'll see you there on the other side.

Dr. Brown, a pleasure.

Alison: Thank you. Thank you, Shireen.

Shireen: Thank you for listening to the Yumlish podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspective. You can also visit our website, Yumlish.com, for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first.

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