How Our Definition of Healthy Fails Black Women

What I’ve learned in my years as a dietitian.

Photo: Getty
Photo: Getty

My waiting room and office space communicate everything I want patients to know: that my work centers those too often overlooked by my fellow dietitians — Black women, femmes, and queer folks. The bookshelves display covers that address body politics and queerness; the walls are hung with life-size paintings of Black bodies, unapologetic in their abundance. My favorite greets me in the waiting room every time I walk out of my office. The figure in the painting has dark skin with gold highlights around their nose and eyes. Naked from the shoulders up, the figure’s face framed by blue-black, kinky hair falling around the shoulders. The strong gaze strikes me as empathetic and calm, a welcome presence in an office that holds many emotions.

Mia is in the waiting room, perched on the edge of my couch wearing a pressed navy pencil skirt and a pink silk blouse with pearl buttons. I glance up at the painting as I exit my office and greet her. Knee bouncing, Mia’s black spiral-bound notebook is moving up and down on her lap. She has relaxed hair that reaches past her shoulders. It is nine a.m. on a Saturday and, though many of my clients would arrive in casual attire, Mia is dressed to be taken seriously.

As we walk into my office, I turn on the white noise machine for privacy and invite her to have a seat. It’s overcast in Oakland this morning; she looks out the window as she gets settled.

We exchange pleasantries before I let her know what she can expect from me: honesty, curiosity, and a political context for her experiences. I find that sharing my style up front reduces anxiety for my clients and allows me to connect with them more quickly. One hour is very little time to hear a Black woman’s story of her body.

Mia begins to tell me about herself. She’s here because she’s exhausted, so exhausted that even a good night’s sleep does not restore her. She’s recently changed insurance and met with a new doctor who told her that her lab results show signs of malnutrition, which is how she ended up in my office. At her last salon visit she and her hairdresser also realized that her hair is thinning and has stopped growing. The hairdresser recommended some supplements for hair growth, and Mia is hoping to get my feedback on these as well as supplements that can fix her deficiencies and increase her energy.

Mia is twenty-four and has just started graduate school in a town close to home. She is in a predominately white aerospace engineering program, the only Black woman in her class. Six months before starting her program she embarked on a “wellness journey” after her previous doctor told her that she was obese. That doctor told Mia she needed to lose weight to reduce her risk of developing chronic diseases, ones that she is already more likely to get because she is Black. Her body, from that appointment on, was a risk factor. Mia hadn’t thought of her body in such a pathologizing way prior to that appointment. Hearing how the doctor problematized her body was disturbing to Mia; she lost the weight he recommended and more. She scoured the internet for advice and looked up ideas for “healthy meal prep.” She stopped eating as many meals with her family and instead brings over her own containers of food to eat while they share food her mom had prepared. She started going to the gym every day and is now worried to take a day off.

The response to her weight loss has been overwhelmingly positive. She has noticed a shift in her social capital and desirability. Her peers and professors have started looking at and talking to her differently. Her classmates know how much she exercises and praise her for taking the time to do so when the academic workload is so overwhelming they don’t even have time to sleep. Mia appreciates the feedback and interprets this to mean that she is disciplined and healthy in their eyes. But Mia doesn’t engage with her peers outside of class because she needs to exercise. She also doesn’t join them for happy hour because she doesn’t want to pay for a side salad — the only thing she eats at restaurants — because she could make the same thing at home for less money. And besides, the alcohol is just extra calories that she doesn’t need.

I ask Mia about her days, and ask more specific questions about how much she is eating and how much she is exercising. I ask her which supplements she is already taking. We discuss what messaging she got about food and bodies as she was growing up. As we continue to talk, she gets visibly impatient. She tells me that she came here for me to tell her what is missing in her diet so that she can take supplements to make up for it, that’s all. I realize that my attempts to build rapport aren’t what’s needed in this appointment and decide to be clear about my concerns. I tell Mia that her energy levels will likely improve and her hair may grow back if she begins to eat more food and exercise less.

I see the confusion on her face, the subtle frown line and slightly raised eyebrow. She tells me, “That can’t be the problem; what I’ve been doing is working, it’s getting results. There’s just a vitamin or mineral missing from my diet; maybe magnesium?”

“I understand your concerns,” I say, “but from what you’ve told me I don’t have concerns about your vitamins and minerals, I have concerns about calories, fat, and protein.”

“But I’m the healthiest I’ve even been in my life! I eat intuitively now, my body doesn’t like any of the foods that I used to eat; it prefers vegetables and fruit.”

When I ask Mia if anyone has expressed concerns about her food restriction and rigidity, she assures me this isn’t what’s going on here — it’s not about weight loss or the thin ideal; it’s about her health and feeling good in her body. I ask whether people have talked subtly about her food, and she tells me that her sister has noticed what is going on and offered to support her. But Mia doesn’t need support; she just needs me to tell her how to fix the problem so that she can get her energy back and thicken her hair.

I hear this regularly. It’s not about dieting. It’s about “health” and “wellness.” It’s about feeling “clean.” And because this pursuit of wellness also feels like a pursuit of purity and morality, she is happy to perform whatever rituals or sacrifices may seem necessary to contain her body.

I explain to her how energy deficits impact the body and why this would explain her experiences and lab results. She listens, opens her mouth to say something, and then pauses. She looks out the window and becomes tearful. “I can’t be the only Black person in my class and also be fat,” she says. And there it is, the reason why Mia is here: the impacts of white supremacy on the body narratives of Black women and the safety found in conforming to what whiteness demands. All I can do is nod. Black women are tasked with existing in a society that views us as disposable. The politics and constructs that shape society also shape our bodies.

I tell Mia that I often see marginalized people engage in practices that can negatively impact their well-being in order to lessen microaggressions, organize their day-to-day actions, and strategize existence. Navigating a competitive, predominantly white graduate program is hard enough. Mia tells me she fears that if her body conforms to the stereotypes of Blackness that her classmates have, she may finish the program but won’t have the networks she’ll need to advance in her career. In Mia’s mind, becoming thin is not about being a certain dress size; it is about survival. If others perceive her body to be a disciplined body, she knows she will be treated with more respect by classmates and professors.

I tell her I know she began her wellness journey with the best of intentions. And that I understand how the positive feedback and attention she’s getting for having lost weight make it easier to navigate everyday life.

Mia is quiet. I am quiet, too. I want her to take her time. After a minute or two, her feelings bubble up. She wipes a tear from her cheek and tells me that, though she may agree with me in theory and understands that eating food may give her more energy, she just can’t gain weight — it’s too much of a risk. In fact, she would like to lose more weight “to be safe.”

I know.

Our safety is contingent on how little of a threat we pose to those around us. If we can make ourselves smaller both literally and figuratively, we may be able to uncouple ourselves from the savagery associated with our Blackness. Our humanity is tied to how well we can conform to what whiteness demands. We might swallow parts of ourselves, rather than food, to become more palatable to others. We may hold ourselves and other Black women to higher standards than we would any other group of people. We seek respect, and get tripped up in respectability. Our survival in society directly correlates with our resilience.

I am one of the 3 percent of Black dietitians who make up the field. In my coursework I was “taught” about Black people and what “they” eat and what to tell “them” about nutrition. Similar to Mia, I was taught that the bodies of Black people are inherent risk factors just for existing. In my training decades ago and at conferences into the 2020s I hear about Black people’s individual responsibility to take three buses to get to a grocery store to buy whole grains and leafy greens, quinoa and kale. Southern food is constantly vilified by dietitians and directly associated with Black people at the same time hipsters and gentrifiers are enjoying a renaissance of ribs, pork belly, greens, okra, mac and cheese, chicken and waffles, and cornbread. When the same foods that are pathologized in the context of Blackness are associated with thin, white, affluent people, they become a foodie’s gastronomical paradise.

For the majority of my career, I have worked with people who have restricted their food and/or have tried to shrink and contain their body in some form or another. I have been the only person of color in a room full of eating disorder clinicians more times than I can count. Multiple times I have been approached by conference attendees who call me by some other name because they think I’m the one Black clinician they know. I somehow always end up in the corner, visible and obviously out of place. The eating disorder field has never been ready for me and the truths I tell when I show up. It has never been able to support my clients.

When I look in PubMed, the National Library of Medicine database, and type in “eating disorders” and “Black women,” only a dozen results from the last five years appear, and only one study of Black women exclusively, while the majority compare Black women to white women, who are clearly defined as the norm or default sample population. Meanwhile, there are more than 8,000 results for “eating disorders.” I don’t think it is ethical to say that we’re providing “evidence-based” care to Black women with eating disorders when they are present in .001 percent of the research.

In my training to become a dietitian, I didn’t learn about the structural forces, epigenetics, toxic stress, or trauma that impact the food choices in marginalized communities. As dietitians, we’re educated to believe in individual responsibility; we’re taught to tell our patients to “eat healthier” and that the only barrier to doing so is their willingness.

As training was limited, it was easy to adopt the common perception in the field that all women adopt disordered eating patterns for a sense of control and a desire for thinness, visibility, status, and the male gaze. Eating disorders in Black women and other folks whose bodies don’t conform to societal requirements are often different — and more harmful — quests. White women, by virtue of being white, are closer to this culture’s racist body ideal, and therefore closer to feeling safe and seen, even as they may also hold marginalized identities. Black women will never come close to the body ideal that whiteness upholds — thin will never be thin enough to tame a Black woman’s body.

This harm not only validates disordered eating for Black women but also leads to internalized anti-Blackness and shame.

I am constantly focused on how to care for bodies that are stereotyped as strong but that are, in reality, deeply vulnerable to the manifestations of white supremacy. In my practice, I help my patients contextualize how the narratives written during enslavement continue to exist today. Black women often take on the false idea that we have superhuman strength and resilience, in the meantime sacrificing our physical and mental health trying to make ourselves fit into a society that does not want to accept us. This replicates centuries of lacking body autonomy for Black women, of being denied agency in how we tend to our bodies.

Early in my learning I would have approached Mia from a place of already knowing. I would have told her she needed to talk to her doctor about getting an eating disorder assessment. I would have created a meal plan for her and a goal of trusting her body and eating intuitively. But I don’t. Instead, I listen.

At her appointment, we discuss the influences of whiteness on her reality, and I validate her experiences. I tell her I don’t have The Answer because her experience is rooted in both her lived experience and the politics of the external world.

She isn’t ready to hear about this. She isn’t ready to give things up. And that’s okay.

A glance at the clock tells me our time is almost up, and I offer Mia a follow-up appointment. As she disappears down the hallway, I lean back against the wall and look again at the painting in my office. I let out a deep sigh. These moments never get easier. After appointments like these I feel a mixture of sadness, anger, and despair. The first few times it happened, I teared up, at a loss for how to problem solve something with clients that was impossible to fix; fixing was something I’d been trained to do. I’d sit in silence as clients shared their trauma, knowing I couldn’t change anything about the past, and wonder what my role was in these situations. The realities of living under white supremacy never get easier, but over time I’ve found ways to channel my energy into collective and cultural change. One thing that helps is having clients trust me with their stories. Supporting them on their path to healing is my healing, too.

From the book It’s Been Always Ours: Rewriting the Story of Black Women’s Bodies by Jessica Wilson. Copyright © 2023 by Hachette Book Group, Inc. Reprinted by permission of Hachette Books, an imprint of Perseus Books, LLC., a subsidiary of Hachette Book Group, Inc., New York, NY. All rights reserved.

How Our Definition of Healthy Fails Black Women