Bradley Flansbaum
Posted 4/12/12 on The Hospitalist Leader
There is a lot of talk these days of personal responsibility. Obesity, lifestyle choices and any untoward consequence of either are usually attributed to the individual, and the cost—both financial and in quality of life—are duly theirs.
As you will discover, this post will not deconstruct the literature base behind that sentiment. It will however encompass some parts anecdote and intuition, as well as a few life lessons. On the latter, if I convey by half a bit of my own takeaway, I will have achieved just rewards.
For framing, early in my training, I fervently believed that obesity, poor food selection, and lack of exercise were a choice:
–No gym membership? Hit the pavement.
–Dearth of fresh vegetables? Buy frozen.
–Have lower back pain? Look in the mirror.
That was long ago.
It stemmed from inexperience, adverse sway in residency (still rife in programs today), and a shortage of familiarity with the forces behind one’s life options. These outcome-shaping lifestyle choices are not availed to all. And as a sobering gut check, just when I think I comprehend the determinants of health that allow individuals to pursue these alternatives, life imparts a new lesson.
In that vein, we all make the usual assumptions—suboptimal education, ethnicity, place of residence— are consequential and produce the disparities in society with which we are familiar. However, these influencers, while real, are in the abstract and it is not until we challenge ourselves, do we see the sometime expansive distance between our patients and us. What we discover on probing can be surprising.
If this is still revelatory for a clinician, administrators and policy makers take note: you cannot get here from there—behind a desk, in an office, festooned behind a PC day after day. You must experience people firsthand.
Dawn (not her real name), has been my patient for five plus years. I have admitted her over fifty times, and I know and identify with her well. As a hospitalist, I have become her surrogate primary care physician (along with her ambulatory PCP).
She has a chronic illness, and commendably, struggles to keep a job, attend school, and care for her extended family. She has a solid social safety net and maintains a semblance of life between admissions. Suffice it to say, she does the best she can under the circumstances, and would prefer an existence free from the shackles of hospital services if that were an option.
You might be thinking, why no interventions or attempts at transitional or chronic care management? Our emphasis on integrated services and innovative direction of our system these days surely can deliver the right stuff.
Noble question, but without getting into detail, our system has failed her. We try, as does she, but to no advantage. For me, irrespective of readmission penalties, the remedies to this woman’s unfortunate circumstances are not immediately solvable with the resources available (CMS and policy folks take note).
With that said, I engaged Dawn recently in a different sort of conversation, specifically, regarding her gradual weight gain of thirty or so pounds—that she knew she could no longer ignore. This excess is not due to comorbid conditions, but lifestyle choices.
Interestingly, despite a household that rooted its cuisine in the heritage of the south (think bacon grease, butter, pork), she had an understanding that these products were unhealthy; whole grain goods were preferable over those with refined (“white”) flours; and sweetened beverages were bad.
However, as we spoke, she relayed the following:
- As a child, not once did she see milk on the table, and if she invited friends to the house for dinner, and her family did not serve soda, it was insulting and an embarrassment.
- Eliminating fat from her traditional family cuisine was unheard of, and to suggest otherwise to her grandmother—who did the cooking, was heretical and an affront to their customs.
- In her neighborhood, there are few places to buy vegetables and in a pinch, most of her meals on the run were pizza, take out Chinese, and Caribbean or Latino fare.
- Soda equaled sugar, but NOT teas, sports or fruit drinks, as they resided in a more “wholesome” category.
- A culture of eating existed amongst her friends and family that emanated from within her neighborhood, and any external message suggesting otherwise lacked rationale or purpose. This is our “normal,” like your family and “Jewish cooking.”
You get the idea, and the above is not news to astute followers of the nutritional folklore that plagues our more diverse neighborhoods. I could have added another half dozen bullet points.
After speaking to her for some time, and again, I know her very well, I asked her to answer the following questions. I was flabbergasted:
What affected me most was an adult woman—living in a diverse city with every cuisine imaginable, dispensed with cauliflower, eggplant, and brussel sprouts (she added asparagus as well, after the fact), especially with its profuse availability.
Just a sidebar, in NYC, one walks and never drives, and you purchase produce on a daily basis when convenient. The concept of “stocking up” does not exist, and outdoor vendors are plentiful. Just three blocks from my hospital, in an affluent neighborhood, this is what you will discover:
Suffice it to say, you are not left wanting with these healthful choices, and this selection is what you typically find south of 96th Street. On the latter, 96th Street is a geographic demarcation in Manhattan that separates the advantaged Upper East Side, from the more ethnically distinct neighborhoods of Spanish Harlem and Harlem—Dawn’s general environs.
I am very familiar with her neighborhood and occasionally make an outing. The sounds, colors, and people are more than welcoming, and it is a wonder of NYC that within just a mile radius, this diversity exists. However, amidst this diversity, you will not find food choices like those depicted in the photo.
I decided to visit again, near Dawn’s block, but now with a more discriminating eye and the zeal of a missionary. How hard was it to select foods wisely in this part of the city?
On arrival, I noted some pleasantly renovated stores near her address, but in my search for carts–at least those that rivaled my neighborhood’s own, this was all I found within 5-7 blocks :
Actually, the fruit looks rather respectable, but vegetables were absent. Unquestionably, it would be a chore to exit the subway after work and find an eggplant. Additionally, when I asked the seller, “Why no vegetables,” I got a terse response, and a predictable reply: “Because nobody buys.” He knew what I was reaching for, and sensed the photo had a greater purpose.
I wandered the streets a bit, and in addition to the usual fast food outlets, there were plenty of establishments like this:
The food selection on the steam tables were mostly fried or fat laden, and the only vegetables present were lettuce, tomatoes, and onions, and then only as condiments to main dishes. The beverage refrigerator had mostly sugared drinks, and what was surprising, even for me, was an almost absent selection of diet soda. No demand I suppose, once again.
Regardless, you get the general theme. No arugula. No baby spinach. No quinoa salad. There are options within these neighborhoods to be sure, but they are hidden and not overtly available. It would take effort to find “the good stuff,” and even then, probably at a premium price. The reasons why go beyond this piece, but if you have gotten this far, you can probably fill in the blanks and make some astute guesses.
How then does a physician effect change? Some folks feel that a five or ten minute conversation with a patient concerning dietary modifications is adequate. Most who practice in this sphere are skeptical, and to think that a few helpful pointers will tip the balance in favor of healthier living and move any patient–regardless of life circumstance–into a more favorable health outcome category is a stretch. If you need validation, just search the literature.
Additionally, spend a few hours outside the hospital or office in unfamiliar surroundings, and it is apparent you will face a Sisyphean charge. It is not an n=1 task and that realization makes the gutting of programs such as the Public Health and Prevention fund so frustrating. It takes a village and efforts to improve neighborhoods like these won’t rest on a brief office visit where the message is, drink less soda and move more.
However, not to conclude on a negative note, there is a bit more to the story. Knowing Dawn, I was certain with the right motivation, a slight “culinary” nudge might provide inspiration. Not just to try new foods mind you, but for her to gain confidence and adopt new habits to achieve a healthier weight.
Alas, being a lover of all things green and leafy, I roasted some brussel sprouts for her to try:
Obviously, for confidentiality purposes you can’t see her face…but you do see a sprout. And yes, there is a smile there, a big one, and she wants the recipe. She loved them.
With that special patient, maybe n=1 can make a difference, and hopefully, good things will follow. It certainly made me feel awful nice.
Care And Cost 