I love food. Whenever I grocery shop, cook, or eat, I enjoy myself thoroughly. I avoid labeling myself as a “foodie,” though, because it implies a certain snobbishness. Sure, I’m a regular customer at Whole Foods and have been known to purchase low-fat goat cheese and heirloom tomatoes. But I also buy cheese puffs and chocolate-chip cookies once in a while.
As a supermarket junkie, I can easily empathize with overweight patients. As a budding cardiologist, I lament their situation. Many of my patients want to lose weight and are eager to discuss it. When I first started seeing patients in the office, I would broach this topic with an open-ended request: “Tell me about your diet.” Now I know that this line elicits a variety of vague answers. A few people admit that their diets are less than optimal, but most say that they “eat healthy,” only to be contradicted by the scale.
Every time I see Ms. Watson, a 45-year-old woman with disabling asthma, she says she is “cutting down.” At our last visit, skeptical that she could reduce her intake and still maintain a body mass index of 60, I asked her to be more specific.
“Can you tell me what you ate yesterday?”
“Well, I had four hot dogs for lunch.”
“Did you eat breakfast?”
“No.”
“Buns with the hot dogs?”
“No.”
“Okay, what about dinner?”
“I had two hamburgs with cheese. No buns.”
“Did you eat anything with the burgers?”
“I made some rice.”
“How much rice did you eat?”
She indicated a dish about a foot long and six inches wide. “But I only ate about half of it.”
“So that’s all you ate all day?”
“I also had some mac and cheese.”
My initial reaction was, She lives in my personal dietary hell. I would feel terrible if I consumed only fatty meats and processed starches. As I thought about it more objectively, my assessment was no more optimistic—her cardiovascular future seemed grim.
“You should try to add some fruits and vegetables to your diet,” I said gently. “We recommend that everyone get five servings a day.”
She nodded. “I know I should, but they’re so expensive. And it’s hard to get someone to drive me to the Stop and Shop, where the food is cheaper than at our corner market,” she said, reminding me that supermarkets are known to be sparser in low-income areas.
After our visit, I thought more about her diet in light of her financial situation. With the calculator on www.gettingfoodstamps.org, I found that a single Massachusetts resident receiving disability benefits and no other income is eligible for $155 per month, or about $36 per week, in food stamps. Using the Stop and Shop website, I attempted to plan a week’s worth of healthy meals within this budget. For breakfast, I selected half a cantaloupe and 4 ounces of cottage cheese. Lunch consisted of a turkey sandwich on whole-wheat bread, a banana, and a carrot. For dinner, I chose a chicken breast, broccoli, and a baked potato. Snacks included apples and salted almonds. The weekly total was about $50, and that didn’t even include condiments or beverages. This menu provides only about 1,200 calories per day, barely subsistence level for an average-sized woman. Ms. Watson’s menu, on the other hand, costs about $38 per week and supplies at least 2,500 calories per day (likely more, if the servings of rice and macaroni are large).
In order to help Ms. Watson strike a happy medium, I have encouraged her to try to eat some—or any—vegetables. Substituting frozen or canned mixed vegetables for fresh broccoli would save about $3 per week within my sample menu. As her physician, I know that any small improvement in her diet could help her lose weight, but I can’t force her to substitute salad for potato chips.
The quandary of nutrition in poverty receives some attention in the 2007 Farm Bill, recently passed by the U.S. House of Representatives and about to be reviewed by the Senate. The bill would increase funding to the federal Fresh Fruit and Vegetable Program, providing more fresh produce to schools, and strengthen the Senior Farmers’ Market Nutrition Program, which gives produce vouchers to senior citizens. What about the middle-aged population? The bill vaguely suggests that state governments start nutrition education programs for low-income consumers. But clearly, as I’m learning with Ms. Watson, words aren’t enough.
Perhaps the food stamp program, about to be renamed the Secure Supplemental Nutrition Assistance Program (SSNAP), could play a more active role. Food stamps could be earmarked for specific types of purchases and allocated in healthy proportions—for example, 30 percent fruits and vegetables, 20 percent meats and legumes, 30 percent grains and starches, and 20 percent miscellaneous. Foods high in saturated fat could be restricted. Alternatively, if these options seem too paternalistic, state governments could subsidize grocery stores to sell reduced-cost produce to food stamp recipients.
As I munch on baby carrots tonight, I feel lucky. I like their texture and flavor; I know I’m getting some vitamins and not so many calories; and just as importantly, I’m not worried about my grocery bill. I want all my patients to find similar joy in healthy eating. For the sake of Ms. Watson and millions like her, I hope that high-quality nutrition will continue to rise on our nation’s list of priorities.
Nicole Martin, HMS ’06, is a resident in internal medicine at Massachusetts General Hospital.
The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
