Secondary Logo

Journal Logo

Let Them Eat Cake

Rees, John; Rodriguez, Fatima, MD, MPH

doi: 10.1097/ACM.0000000000002544
Teaching and Learning Moments
AM Rounds Blog Post

J. Rees is a third-year student, Stanford University, Stanford, California; e-mail:

F. Rodriguez is assistant professor of medicine, Division of Cardiovascular Medicine, Stanford School of Medicine, Stanford, California.

An Academic Medicine Podcast episode featuring this article is available through iTunes, the Apple Podcast app, and SoundCloud.

Students are expected to translate the skills they learn in the classroom to real-world situations, but a lesson many of us learn the hard way is how difficult that can be. As a volunteer health educator, one of the guiding principles of my work is cultural competence. I was trained on how to recommend culturally appropriate lifestyle changes with an “other-focused” perspective in discussions with patients; however, I was ill-prepared to manage a situation in which adhering to the principles of cultural competence and promoting healthy behaviors seemed at odds.

In the summer of 2017, as part of a community health project in Oaxaca, Mexico, I visited San Miguel Peras to administer wellness surveys that were part of the Stanford Wellness Living Laboratory project. The project aimed to characterize the lifestyle factors that contribute to overall well-being. San Miguel Peras was a remote mountain pueblo with about 400 families and was primarily made up of family farms. For the survey, we partnered with a local organization called Niño a Niño. On our final day, when the mothers from each family came to pick up the bag of compensatory staple foods they got for participating in the project, the leader of Niño a Niño requested that we deliver a presentation on healthy eating. Because I was a practicing health educator, our professor asked me and another student to lead the presentation.

As members of an isolated community, the food choices these women made were determined by their subsistence-based economy, augmented by a seasonal fruit stand and small grocery store that stocked soda, candy, and other nonperishable goods like rice and beans. Physical activity was limited to work-required labor. Given their circumstances, my partner and I sketched out a plan to effectively engage with our audience. We were both trained in suggesting dietary recommendations based on Harvard’s Healthy Eating Plate,1 so that’s what we chose to use. The problem with the Healthy Eating Plate framework was that it was designed by Americans for Americans, and it wasn’t tailored to fit the lifestyle of these Oaxacan villagers.

We tried to adapt our U.S. training to our audience. We started by drawing a Healthy Eating Plate without any example foods. Then, we went through the day meal by meal, asking our audience members what they ate. As they named foods, we placed them on the plate, explaining which food group they belonged to. Immediately, I saw the challenges. Most of their typical caloric intake was from staple foods and sugary drinks, and their access to other foods was extremely limited.

I felt like the proverbial Marie Antoinette declaring, “Let them eat cake!” How could I possibly ask these villagers to eat fewer tortillas or drink less soda when these staples constituted the majority of their typical caloric intake? By making our U.S.-centric recommendations, we were demonstrating our own obliviousness. I worried that this disconnect would call into question the rest of our presentation and all of my group’s work in the village, because our audience would have little reason to trust our advice if they felt we did not understand their situation. We had chosen to use the Healthy Eating Plate because we were familiar with it, not because it was relevant to our audience, and by doing so we compromised the effectiveness of our presentation.

In situations where cultural competence seems at odds with a health intervention, the question becomes whether the intervention is worth implementing. My inability to understand the cultural realities of our audience meant that I could not be certain that they could cut down on soda and still consume enough calories. What allowed us to educate our audience with cultural humility was taking advantage of audience input. When we weren’t sure if a suggestion we made was possible, we simply asked. When we explained why water is better to drink than soda, we added the caveat that feeling healthy is subjective, so if they felt worse after cutting out a food then they could add it back. By sharing our lack of understanding and jointly crafting health recommendations that were realistic and beneficial to the community, we increased our credibility with our audience.

As I prepare for a career in medicine, I often reflect on this experience in Oaxaca when I truly learned the importance of cultural competence. Medicine requires trust and partnership between patients and providers. I firmly believe in the power of health education to improve health outcomes, and as I continue to work in culturally unfamiliar situations, I must meet patients where they are, understanding their beliefs and the realities of their environments, to ensure that my recommendations are truly culturally competent.

Back to Top | Article Outline


The authors would like to thank Dr. Gabriel Garcia for facilitating the experiences that inspired this essay.

Back to Top | Article Outline


1. Harvard T.H; Healthy Eating Plate & Healthy Eating Pyramid. Chan School of Public Health. Accessed November 21, 2018.
© 2019 by the Association of American Medical Colleges