Transcript

Episode 5: Angel Cunningham

Angel Cunningham

Food is joyful food is delicious. I love everything about food. I love the way it tastes, the way it looks, the way I mean everything the way it smells, we should enjoy it. I never want for somebody to be afraid of a food that they find enjoyable.

Aryana Misaghi

I'm Aryana Misaghi. And this is Appalachian care Chronicles, a podcast bringing you stories from every corner of West Virginia's health sector. Join me as we journey alongside a variety of problem solvers, change makers and daily helpers, who are all working behind the scenes and on the frontlines to care for our communities. Together, we'll explore what they do day to day, the step that got them there and the y's that continue to draw them back. How in the face of some of the most challenging situations possible, do they manage to keep themselves and the rest of us from falling apart? Far from predictable the past they watch are full of twists and surprises, discovery and purpose. This podcast is for anyone who has ever even thought about going into the healthcare field, or has a passion for caring for others in times of need.

Aryana Misaghi

Let me introduce myself your host. I'm Aryana and welcome back for season two. When you last heard from me, I was graduating from medical school at Marshall University in Huntington, West Virginia. Now I'm officially a physician. Being the doctor responsible for my patients mental health is really really special. I'm so excited to be hosting the second season of Appalachian care Chronicles. For these episodes, we traveled around the state from Preston to Boone and back again, to hear from providers who are day in day out delivering a range of care from identifying life threatening disease to preventing disease through diet, from clipping ingrown nails to addressing tooth decay in rural communities. There's a lot to learn this season. In this episode, we meet Angel Cunningham, a registered dietitian in Charleston, West Virginia. Angel specializes in medical nutrition therapy, and pediatric and adult nutrition education. She helps educate and guide her patients to make choices around food and eating habits that help them meet their healthcare goals like managing diabetes, lowering high cholesterol and even learning to navigate grocery stores and nutrition labels to find more healthful options without sacrificing their favorite foods.

Angel Cunningham

Historically, you know, dietitians were known as the quote unquote, food police. And so I start a lot of my conversations with my patients as I am not the food police are not here to tell you what to eat. I'm here just to give you some information and some helpful tips and tricks to help guide you to create a healthy eating plan for yourself overall, there is a ton of misinformation that's out here and I do recognize that so I do try to have open ended conversations and kind of just combat those challenges. You know, the grocery store can be very intimidating for a lot of people. You know, in the past we used to say kind of walk the perimeter, don't go down the aisles because that's where you know, the more or less healthful foods kind of were, Kroger, Walmart have smartened up. So now you can no longer kind of utilize that. So explaining to them you know, the five food groups and then the most healthful foods from those five food groups that also fit into their budget, and then their preferences and their culture. You know, it's so much more than just eat these things. What do you like enjoy it as well.

Aryana Misaghi

When I think of good West Virginia Food, I think of pepperoni rolls, Tudor's Biscuits, and Mountain Dew. I also think of foraged foods like ramps and morales, and farmed foods like zucchini and tomatoes and cabbage and squash. The so called West Virginia diet can encompass many things, and it's rooted in the land and its people. But people's choices around food aren't only influenced by their favorite West Virginia cuisine. People are also making choices based on holidays, sporting events, racial and ethnic cultures and family traditions.

Angel Cunningham

So I am Black. You know, my culture is Soul Food. We like it. We love it fried chicken. It's delicious. But is it the most healthful option for us overall? Probably not. So how do I flip that and enjoy those pieces that I've always loved and kind of grew up on, but in a more healthful way. So now we have things like air fryers, you can still get that beautiful crisp that you're looking for, but in a more healthful way, you know, getting rid of a lot of that saturated fat, you know, helping with our levels, with our cholesterol, high blood pressure, all of those different things, cutting out on a lot of the butters and things that we historically have in our foods, switching to things like olive oil, you know, just helping create, still the flavors that we're looking for, but just a more healthful way of enjoying those and, and keeping us healthy and happy.

Aryana Misaghi

For a lot of patients, especially in Appalachia, Angel might be the first Black provider they've ever met. Angel's culture adds a whole other dimension of possibility to connect with her patients.

Angel Cunningham

I think it kind of gives me a unique ability to relate, you know, it's not just, you know, having a Black person working in your facility, you know. It's for the people that are in the community. It's seeing more people that look like them. And I cannot tell you how many times I peek out in that hallway to grab my patient, and it's a Black patient, and they see me and their entire facial expression changes. I mean, just through the roof of "she's gonna get it," "she's gonna get me" and I do because I like fried chicken too! And that's a stereotype but it's true. I mean, everybody likes fried chicken. But when it comes to Soul Food, like I can relate to you, and then you know that what I'm telling you is not nonsensical, and it's probably gonna taste good. So try it, but then be able to relate and have other people that look and feel like them. And it doesn't matter the color of your skin, I can relate to lots of different colors. I have friends of every different culture, religion, you know, I'm able to reach more people specifically in this kind of area where they need it the most.

Aryana Misaghi

Like many of us in health care Angel's path to helping patients wasn't straight and narrow. She can relate to her patients easily in part because she has experience in other fields.

Angel Cunningham

So my first degree is actually in exercise physiology. I was a personal trainer for years, I absolutely loved everything about it. I went to WVU for my first degree, and then I came back and I had worked in childcare since I was 16. So when I came back home, it was a job went back there ended up becoming the director of the childcare center, extremely passionate, loved the children, loved everything about it. I got involved in a program called Keys For Healthy Kids, which was encouraging, you know, those fruits and vegetables, healthy eating physical activity. And I was just able to kind of see the difference in the family lifestyles. Okay, so children who we knew were eating these things, and we're getting that activity versus the ones who weren't necessarily exposed to those things. And it just made me think more of how can we help them? So I did, talking to those parents about, you know, maybe "Little Sally loves spinach, have you tried spinach at home? She finished her plate today!" and just having those conversations with those families. And then I would get people given them the menus, take them home, you know, if you want the recipe, we'll send it to you, having those deep conversations and they're coming in, oh, my goodness, he tried, you know, whatever it was. And so as I continued that, I recognized I was good at it. I was good at having those conversations and not making those parents feel shame, but empowering them instead. And so I wanted to do more. So then I decided to go back to school, researched it, talk to a professor loved it and then went back to be a dietitian.

Aryana Misaghi

Registered dietitians, or RDS go through a lot of school to be fully certified. To be eligible to sit for the dietitian registration exam. You need both a Bachelor's and a Master's degree plus the completion of a dietetic internship of at least 1200 hours. That's 30 weeks of full time work. RDS can end up serving in a variety of roles. Clinically, they can provide medical nutrition therapy, and they can design customized nutritional programs that address the health needs of patients. In the community, dietitians create programs and provide guidance to the public on food health and nutrition. And yes, there is a huge difference between dietitians and nutritionists. Most importantly, dietitians function within a highly regulated industry that requires specific education, training, experience and licensure. Most medical schools don't teach much about nutrition. Your doctors are largely trained in treating illness, not optimizing wellness. That's why dietitians are specially trained in nutrition. It's a broad topic with lots to cover.

Angel Cunningham

Everything that we put into our body has an effect, right? Whether it be fully physiological, whether it is you know, something to do with our weight, our mental health, you know, there are so many other things that food does for our bodies, our vitamins or minerals, protein, you know, I talked to them about what those different foods do for your body. So again, not always having to relate it to weight, but protein. What does protein do for you make your muscles better? Get strong. Don't you want your muscles to be big and strong? Yes! Food is medicine. What about vitamins and minerals? Oh my goodness girl, your hair is beautiful. Your skin is so pretty, you know, what does that? Your fruits and veggies. Food is medicine. Okay, whenever people are able to get their A1C's under control and get off of Metformin, or other diabetes drugs, they are so happy, and they're controlling that through food.

Aryana Misaghi

The concept of “food as medicine” cannot be overstated. Before seeing it in person, I even had trouble believing that a person's diet actually had the power to have any effect on disease like diabetes. Genuinely though I have seen people's blood sugars returned to normal within a year by changing their diet alone. When I say diet, though, I don't mean a short bursts of time of limited food intake that isn't sustainable in the long term. What we eat 80 to 90% of the time, that's what has lasting impact on our health. That's not a diet, that's a lifestyle change.

Angel Cunningham

I get patients in here that are like “I just can't eat healthy, because it's convenient to go and it's cheaper to go through McDonald's.” I have literally sat with patients and pulled up, you know, Walmart and pulled up bologna versus low sodium turkey, same price. So doing those cost analysis, it might take a little bit more work, and it might be a little bit uncomfortable at first for them to get into that mindset. So you just have to get them open and willing to have those discussions. Of course, we know that poverty is huge. We have a lot of people that are on food assistance. There's no shame in that, but then guide them and teach them what those more helpful decisions are. SNAP benefits are great. But there's no restrictions, right? You can go and spend all of your benefits on candy if you want to. Let's educate them. Let's empower them. Let's teach them starting young getting in our elementary schools getting in our preschools, our childcare centers, teaching them and guiding them to make those more helpful decisions. And then overall, showing our people even those that are in poverty, you know, even those that are in food deserts, how they can make more healthful decisions, giving them recipes, access, having cooking classes, putting the community back into food, we've got to put our money where our mouth is get back out there and really, really just help our people.

Aryana Misaghi

Appalachian care Chronicles is made possible thanks to the West Virginia Higher Education Policy Commission, and Claude Worthington Benedum Foundation serving communities in West Virginia and southwestern Pennsylvania since 1944. The West Virginia Higher Education Policy Commission administers the Mental Health Loan Repayment Program, which is designed to support mental health professionals currently practicing in underserved areas by providing help repaying student loans. Learn more at collegeforwv.com. That's collegeforwv.com.

In Angel's role as a registered dietician, she has a unique view into West Virginia's food landscape, how food culture and food access intersect, and the ways that impacts the health of West Virginia as population. People in more than 40 counties in West Virginia endure some sort of limited food access, with many of them meeting the USDA definition of a food desert. For people living in a food desert, often their main source of groceries is the local convenience store or gas station. Helping people eat healthfully with limited access to fresh fruits and vegetables is a major challenge that dietitians face.

Angel Cunningham

You get lots of people that want to grow their own produce, lots of people that do grow their own produce, lots of people who are afraid to go grocery shopping at like a Kroger or a Walmart because they don't know what's in the food. So if we can make those resources more readily available, I know that Kroger is now taking produce from local farmers, which is beautiful, and just you know, getting out in the community talking to our people getting rid of those misconceptions around you know, “People don't want to change. People don't want to eat these things. We just want to drink Mountain Dew and eat candy all day.” Not true. They just need help. Maybe it's the budget. Maybe it's not necessarily you know, I can tell somebody what to eat all day long. If we don't have the resources to purchase it. What difference does it make?

Aryana Misaghi

Getting support from a registered dietician is obviously a big step to making nutritional changes in your life. There's also value in finding connection with others who are facing the same challenges. For some patients. Angel recommends health classes and workshops that focus on specific topics where instructors share healthy eating strategies and where patients can find a community of people and learn from their lived experiences.

Participant 1

I've learned how to read my labels better, how to control my eating habits. I learn that I can do exercises. I'm eating more healthier. I've lost some weight, and I'm trying to keep it down. And I've set goals for myself through the program. And it's helped out a lot.

Participant 2

I went through a stage of where my husband was diagnosed with cancer. And so I concentrated on him and basically neglected myself. I got to a point where I couldn't remember if I took my medicine, if I took my shots, it's because I was concentrating on him, you know, 110%. And then after he passed, like, well, normal, I went into depression. And I really let myself go. You know, when I did start taking my readings, again, they was in the four hundreds. I'm like, “This is bad, I gotta get this under control somehow.” So when Laura told me about this class, it's like, “Okay, maybe they will have something that I'm not aware of,” you know, that would help me get it back under control. I feel better. I've lost weight, I'm more active. And one of the things on my bucket list is to live and see a great grandchild from each one of my grandchildren. Plus, I’d like to go zip lining! I'm an adrenaline junkie!

Participant 1

I mean, at first, I thought, “Sell, what are they gonna tell me everything I eat is not right?” Well, no, that’s not the way it was, and the recipes really helped. Because I mean, they would show you different ways of fixing stuff, like take lettuce and put other stuff with it instead of just lettuce and tomatoes and cucumbers, but other vegetables in with it. And, you know, just like one night they fixed the guacamole with onions and tomatoes. Well, I've never seen it like that. And it tastes pretty good.

Participant 3

If you listen to what they say, and do what they say, even though sometimes you do get off track, everybody messes up, get back on track, you will feel the effects of it to will, you will progress. It helps you mentally to physically and mentally. I've totally enjoyed this, we're begging Angel to keep something going. So we can all at least this group meet together.

Angel Cunningham

You’re doing amazing, I'm very proud of you, you’ve got to be proud of yourself!

Angel Cunningham

Life's hard, you know, it's a struggle. And food a lot of times is used as a coping mechanism. And I ask them that what is your relationship like with food? And allow them to answer that, whatever it may be. But more often than not, it's not a positive. It's not more often than not, it is I tend to overeat when I'm sad, I tend to overeat when I'm stressed. Maybe I don't eat at all. Okay, so Food plays a huge role in kind of the way that we feel and vice versa. So getting them comfortable with having those conversations, and then this, again, is not a one stop shop, do I need to make a referral? Are you interested in seeing somebody? Because we have that we have therapists here? You know, do I need to send a referral to one of them, talk to your provider about it? You know, what medications are we taking? Is there something that we can kind of change? Do we need to talk to them about that. So there's so many other things. And then of course, using food as a mood booster. I've had patients that came and said, I started eating fruits and vegetables. And I kid you not, I'm starting to feel better. And maybe I've made no other changes, maybe the scale has not moved at all, fine, but I feel better. So getting out of using food as a coping mechanism, finding other ones more helpful ones, whether it be exercise, you know, cooking, you know, other things that we can do without kind of creating that sedentary kind of lifestyle, and falling further and further into that depression, you know, is just really, really helpful for those patients. So I joke a lot, and I even had a patient that came in who wasn't there. But she said, this is a whole therapy session. And I'm like, but that's fine. You know, and then if you need to see somebody after that beautiful sometimes my entire conversations, nothing, we don't even touch food. We're just talking and then the next time maybe they're open and well, they’re ready to talk about that. But sometimes maybe they just need somebody to hear them, get it out. And then we touch on a couple of things. And I'll see you next time and then we'll dive into your food. So just really just being listening here. A lot of times, especially for the people that are struggling with anxiety and depression, including our children. I can't emphasize that enough, including our children. They're having a tough time.

Aryana Misaghi

Angel knows that food represents more than just what we eat. It's a deep connection to culture to family and frequently, for those experiencing health challenges, to comfort. In her job, Angel works with patients on more than meal plans, she helps them heal themselves by improving their relationship with food. When Angel thinks back to the beginning of her career, one patient sticks out in her memory. This patient was struggling with his eating habits. And with a little further investigation, Angel discovered that his problems stemmed from something much larger: the recent death of his mother.

Angel Cunningham

I was working in a clinic. And, you know, early on, I always just wanted to tell people, everything that I knew, you know, you want it to match when you're in school, and you just want everybody to know what you know. And we had a physician that came in, and I could hear, not wanting any parts of talking to the dietitian, not a single part and talking to the dietitian. But she came in and still wanted us to go talk to him, he was having some issues with his blood sugar, you know, just really needed some assistance. And so although I heard him say “I don't know, I don't want to parts of it,” went in there to speak with this man. And through our conversation, you know, he had had some some extreme weight loss and other issues, but through our conversation, I learned that it wasn't necessarily that he wasn't wanting to eat or that he was wanting to make poor decisions. He had recently lost his mother. And so food became sad for him, he didn't want to think about it, his mother was preparing his breakfasts and his lunches, he would come home, after he was working, would drop off his pail, she would have him dinner, and would have his lunch packed for the next time. And so that was just kind of his routine. After he lost her, everything changed, right? So he just stopped, kind of altogether. And when he was eating, it was just not, you know, the most helpful decisions. And so, in that moment, it was just listening to him and recognizing again, that it's not telling somebody what they're supposed to eat. It's hearing them and recognize when he's hurting. And so let's talk about some other things that we can do what's going to encourage you to now make more healthful decisions. So we talked about maybe at some point, using mom's recipes, you know, and remembering her and making it be a positive, tell me some stories about your mom. And he was able to do that. And through that conversation, and at the end of that conversation, I could tell that he had warmed up and kind of gave the whole like, “This is not what I thought my conversation with the dietician was going to be,” and he was willing to open up that recipe book, and start even I think we decided on maybe a Saturday or a Sunday to try to make one of mom's recipes. And that's just so special. That was one of the highlights that changed my entire outlook, and taught me the importance of that motivational interviewing, you know, what motivates you to make a better decision. And if we can tap into that, and you can recognize that in yourself, you're going to do what you need to do to live that healthy lifestyle.

Aryana Misaghi

People's relationships with food are complicated, and multifactorial. For most people, there's a social component that has its roots in family and then home for this patient. And for Angel herself, food is closely tied to their mothers. Angel comes from a huge family, we're talking seven brothers and sisters and their mother set the tone for Angel’s feelings about food for the rest of her life.

Angel Cunningham

My mother did have a lot of issues. And she was able to recognize that, you know, hypertension, overweight, obesity run in family, different types of cancers. And so she recognized early on in my childhood that she needed to make some changes. And so leading by example of, you know, maybe it wasn't always that, “Watch what I do,” you know, maybe it was some, “Do as I say, not as I do,” but that was okay, because again, I was never shamed. You know, she just instilled those fruits and vegetables at every meal. And that alone is phenomenal. We didn't have sugar sweetened beverages, you know, we drank water, we were encouraged to be active, you know, even if it was just her by herself, shipping us to whatever activity that we were in, she was going to make sure that it happened and just instilled those great positive eating habits and I loved food. And I still do, but it was always positive. It was always love. It was always, “How is this going to make my body feel?” And I just learned from that you maybe she didn't necessarily know what what was happening with the foods that I was putting into my body. But she listened to the professionals, you know, and she knew fruits and vegetables if nothing else. And that was a great start. A lot of times, I hear a lot of patients who don't have a healthy relationship with food, you know, maybe they've had a previous experience where, you know, a lot of us grew up in the kind of the clean plate room where you know, food was scarce. And so you want to finish it because we don't know when we're gonna get more or maybe we don't have a lot of money. You know, the budget was tight. So a lot of people have kind of developed this unhelpful relationship with food and I never had that, you know. I was never forced to finish my plate. I was never shamed for not liking or not wanting something. Now maybe I wasn't going to get something else. Maybe that was what we're gonna have, but I wasn't ever made to feel guilt, or ashamed of my food tastes, my preferences, anything that I enjoyed. And so I took that away from my mother. And you know, it's just so special to me that whenever I'm hearing these stories I can understand and I want to help guide them. I don't necessarily relate to it, but I can hear them. And I want them to be able to kind of relate to my experience, and kind of change that for the generations that are going to come after them.

Aryana Misaghi

It's clear that Angel approaches her patients with great information and great empathy. She anticipates any fears her patients may have and addresses them quickly, indicating that they are truly on the same team. She also uses quite a bit of humor.

Angel Cunningham

Oh, I'm hilarious. And the funniest person that I know. So we just have a good time, a lot of times and I, you know, try to start every single conversation with my patients with how are you? How are you doing? Maybe that's the first time in a day, a week a month that they've heard that they've got so many other things going on in their world? Maybe, you know, they haven't had any communication. I know during the COVID time, you know, people were alone. Okay, so if I can just ask them how they're doing and allow them to express that. Tell me a little bit about yourself, you know, because they come in here, and they're ready to just be shamed, really. I mean, they come to the dietitians office, and they're thinking that I'm going to shame them and make them feel guilt. Not that kind of party. Okay, so ask them how they're doing. Ask them about themselves, get to know them, tell them a few things about me have a conversation. And then I asked them, What can I do for you? And allow them to tell me and maybe they'll start out with? Well, my doctor wants me to lower my A1C levels. Fantastic. What do you want to do? So it's giving them the power to assist me to guide them and making the most helpful decisions for them at that point. They trust me, and they're gonna want to give me some information, they see that she cares. You know, it's not necessarily about what I'm saying. It's the way in which I'm saying it. And that's more important to me than really anything else.

Aryana Misaghi

Like any health care provider, Angel encounters a lot of barriers in her work. From insurance and paperwork to fads on TikTok. She is tasked with helping her patients overcome their own barriers that may often seem insurmountable. What keeps her centered is seeing the real life impact her work has on the people she encounters.

Angel Cunningham

I mean, really just seeing your patients smile, and hearing them. You know, we talked about goal setting, but goal setting is not me to set a goal for you, it's for you to set a goal for your for yourself with my assistance and guidance. And so when you reach that point of “Okay, so what do you want to do?” and then “How do you want to get there?” and “Here's how I'm going to support you do that,” and just seeing them transition from you know, kind of the world is falling, to know it isn't, and everything's gonna be just fine, is the best feeling in the world. I mean, it is just the best feeling in the world.

Aryana Misaghi

Appalachian Care Chronicles is a production of the West Virginia Higher Education Policy Commission Health Sciences Division. Special thanks to the Claude Worthington Benedum Foundation, and to FamilyCare Health Centers. For more information about educational opportunities related to health care in West Virginia, visit appcarepod.com. That's appcarepod.com.

I'm Aryana Misaghi and you've been listening to Appalachian Care Chronicles. In our next conversation, we'll sit down with Zach Grimes, a pathologist whose work diagnosing disease took him from Pocahontas County all the way to New York City and back again. See you then.