Pound foolish

Gerald (not his real name) is an overweight, middle-aged man with diabetes and heart disease who came into the clinic for problems with his liver and fluid retention in his belly. My preceptor (that’s a doctor who nobly agrees to host a newbie med student in clinic one afternoon each week) had seen Gerald two weeks before. He tweaked Gerald’s drugs, stressing the need to take his water pills and improve his diet. Now, Gerald was back for a follow-up visit. He hadn’t lost any weight, a sign he still carried extra fluid; we thought we’d have to double up his pills. I went in to talk to Gerald by myself.

Gerald hadn’t lost any water because he hadn’t been taking his pills. He said they nauseated him. We talked about a bit about the importance of the pills and possible ways to handle nausea, and then I turned to his diet. How are you managing to limit salt, I asked. Great, he said: I never salt my food. I was happy for a moment. Then I asked what he eats. Frozen dinners. Onion rings. French fries. Potted meat, when he can afford it. In short, prepared foods packed with sodium. I pointed this out, and asked if he reads the sodium content on labels. Sometimes, he said, but mostly he tries to get as much volume and protein as possible for the money. Gerald explained he only has $80 a month to spend on food.

We talked more about diet. I noted that he has diabetes, and his blood sugar levels were about three times normal, despite drug treatment. He knew the numbers were high but thought they were pretty good – lower than his sibling, whose diabetes must have the control of a cattle stampede. Besides, Gerald said, he was doing what he could with $80 a month to spend on food.

Gerald’s diet was a big source of pain. His diabetes was most likely causing his tummy troubles by damaging the nerves that serve the gut. That discomfort kept him from taking his water pills, at the same time his diet offered the sodium load of a Polish salt miner. None of this helped his liver, not to mention his heart. But Gerald felt he had few diet choices on $2.63 a day. In fact, he was running out of food and skipping some meals.

Gerald needs to eat better. His poor diet is partly his fault, but it’s partly ours. Gerald gets public assistance, but said he’s maxed out his income and can’t afford more food. He would have trouble affording better food which, sadly, often costs more than junk. If Gerald doesn’t change his ways, he’s headed for a major health crisis. He is one of the 93 million U.S. residents covered by public insurance. That means society will pay for the amputations and ICU stays. We won’t pay an extra $100 a month to help him eat better. But we’ll pay $25,000 for his angioplasty or $65,000 for his bypass (that’s 54 years of $100-a-month food supplements).

The federal government spends about $850 billion on health care, more than anyone in the world, and we have the 42nd highest life expectancy. The USDA spends about $54 billion annually on food stamps. One in seven U.S. residents can’t regularly buy sufficient food. Obesity and diabetes are epidemic. I can’t promise that more nutrition assistance would reduce health spending. But let me ask you this: Where would you spend the money? Because, one way or another, Gerald’s bill is yours to pay.

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Comments

  1. None of this helped his liver, not to mention his heart. But Gerald felt he had few diet choices on $2.63 a day. In fact, he was running out of food and skipping some meals.???????????

  2. I am a single adult resident of Oregon state with no income because of a health disability and I receive the allotted $200 per month in food stamps (SNAP). Why is Gerald not on this program? Shouldn’t our health care system be linked up to refer patients to these resources?

    The SNAP program includes access to programs about nutritional eating. http://www.oregon.gov/DHS/assistance/foodstamps/foodstamps.shtml
    Since I’ve been on the food stamp program, my diet has improved tremendously. Cooking small meals from fresh produce (usually non-organic unfortunately) is less expensive than those frozen meals. It’s about education and re-training our habits. A head of lettuce isn’t that expensive and eggs can be a healthy source of protein on a salad for a diabetic, as you know.

    I do appreciate your compassion and sympathy, but sometimes the money and programs are available, people just aren’t accessing them.

  3. It makes my heart ache to hear stories like this. If a healthy 20-something with a low-income job can get SNAP benefits, this gentleman should be able to get them as well. I certainly hope that somone shares this information with him and he gets the help he needs.

  4. Hi, Jenny,
    I didn’t have time in our visit to get Gerald’s full information about his assistance; I took his word for it that he had maxed it out. That said, I have reasons to suspect he wasn’t budgeting what income he did have in the healthiest way, or making the healthiest food purchases possible. As I said, he bears responsibility for this.
    What got to me was the broader realization that, however he’s doing with budgeting and diet now, it would be relatively cheap to offer additional help now compared with the likely future costs of inaction. It’s one example of a trend I’d noticed that has only been reinforced by a year in med school: We’re willing to pay and do almost anything in health crises, but stingy on prevention. I may have a bias to see that, since I’m interested in primary care. But nothing in my first year of medicine has reined in that interest. In fact, it’s only made me more worried about the focus on tertiary care over primary care.

  5. Dr. Dworkin,
    I agree completely, I just also want to add that what we’re looking at in terms of financial health care reform is putting to heavy a burden on the health care system. There needs to be a more unified social work, safety net reform to assist patients, the elderly, the disabled (like myself), and others needing services. The process of organizing these services and advocating for ourselves is overwhelming. The idea that our primary care physician is supposed to be managing most of this is unrealistic. I think there are ways to reform Social Security and state welfare benefits connected with medical reform that would best benefit the patient and the doctor.
    For example, people like Gerald probably receive Social Security Income of some kind which then decrease his amount of food stamps received each month, giving him the opportunity to budget less for food. It seems an obvious easy fix (and a ridiculously complicated one in terms of politics but not impossible) for him to receive $200 a month in food benefits and less SSI. It might be less comfortable for some people but it would ensure the opportunity for healthier food choices.
    Thank you for bringing up this topic. It affects me personally and I find comfort in knowing doctors such as yourself are advocating for better care overall. I agree there are MANY ways we could spend money to help people live better lives, but I think medical health care reform is only piece of the social safety net system puzzle. And putting ALL of the emphasis on medical health reform puts too great a burden on doctors.

  6. Hi Jenny,

    Glad you are engaged with our website! Thank you for commenting on Andy Dworkin’s post. Just to clarify, he is a first year medical student and his posts and comments are his personal opinion. In fact, all the content on StudentSpeak is generated by our School of Medicine student bloggers – they are doing a fantastic job! Here is Andy’s bio if you would like to know more about him: http://www.ohsu.edu/blogs/studentspeak/meet-bloggers/

    Rob

  7. I so love this. Proper nutrition and health go hand in hand and it’s high time we started putting the two together.Just a few small inexpinsive changes in your diet can make a huge impact on your physical well being. Plus all the money you save in mecication you can spend on better food to eat.

  8. A great story confirming your message about the need for preventative medicine and the real cost of not providing it.

    http://www.npr.org/templates/transcript/transcript.php?storyId=137109975

  9. Thanks for the link to NPR Jenny. What an interesting article. Prompted me to do more research on Cook County Hospital.

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