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.