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Wednesday, January 2, 2013

Life at Grady: Food relationships

I was watching a little girl in the Grady Hospital cafeteria one day. She was standing with what I am assuming was her mother and appeared to be no more than four-years-old. It was a school day, so I'm guessing she was too young to be in kindergarten.

Anyways. She was an adorable and precocious little thing. I mean just as cute as a little button. Talking up a storm with her hand on her plump little pre-K hip. Her pink bedazzled t-shirt didn't quite clear the length of her torso. I could see her belly button and a roll of tummy skin protruding over her striped leggings.

"I want chicken fingers and I want the fries, too!"

"Okay," her mother replied. She then relayed that information to the gentleman working the grill. "I thought you wanted a burger?"

"I do want a cheeseburger. But I like chicken fingers, too!"

"Okay. Well, we can just split it," the mom replied.

"What kind of fries do y'all want?" the grill-guy asked. He stood there waiting patiently with his clear plastic gloves on while patting his brow just below his hair net with the back of his sleeve. 

"Mama, get the mojoes!" the little girl squealed.

"Y'all got some mojoes?" Mama asked.

Grill-guy looked over his shoulder at the fryers. Sizzling behind him was a freshly dropped basket of battered and season-salted potato wedges. "Yeah, we got some."

"Okay. Then give me two orders of those."

And he did. Onto that platter went two cheeseburgers, some chicken fingers and two heaping helpings of mo-joe potatoes fresh out of the peanut oil.

I couldn't help watching them as they walked off. First, a stop at the soda machine where two cups were filled with what looked like some kind of cola. I'm not sure if they got dessert. My guess is that they did.

That little girl's mother had to be at least 300 pounds. And I'm almost certain that the child was well above the ninety-fifth percentile for weight yet in a lower than average centile for height.

Now. Everything about their interaction was loving. The child appeared very well cared for-- from her matching pink outfit to her hair accessories of the exact same hue. Her mother kept her hand on her daughter at all times, and occasionally pulled her close into her side for an affectionate squeeze. That part was sweet.

That part was. Sigh.

I've been thinking about food relationships more and more over the last few years. Instead of telling my patients what and what not to eat, I often talk to them about their food relationship. Do they even have any idea about it? I ask questions like, "Can having an unsatisfying meal ruin your evening? You know  --like if you had your mind fixed on one thing but it either didn't turn out like you'd imagined or even it wasn't available for you to eat?"

I also ask how they feel when eating certain things. Or if there are things that they used to eat but no longer will. If the answer is yes to that last question, I ask why.

Here's what I'm learning from all of that: Food relationships start when we are children. Then, as adults, they can shift in a number of different directions depending upon where we are in our minds. For example, someone who always had full access to their family pantry and who was forced to clean their plate, might do the same with their kids. Or not, if they've shifted their own thoughts on food and eating as they've grown older and learned different things.

Different things? Things like how no matter how much you run, jump, leap and stretch, there comes a point in every adult person's life where weight will never, ever be controlled without redefining food ideas. Period.

Let me just say that this is my own opinion. Nothing really scientific, although I'm certain there is likely some medical literature somewhere to support it. What I mean is, these ideas have a lot to do with my own interpretations of things I've seen over the years. As a doctor and as a regular old person.

So that brings me to mojo potatoes. Have you ever had them? Well, I have. And let me tell you something-- they're delicious. Look. I'm no different than the next guy when it comes to enjoying fried morsels of yummy-ness. But where I am when it comes to such things has changed over the years. Lots of that has to do with my relationship with food growing up. But most of it has to do with the shifts it made in my adulthood.

Will I eat one or two mojo potatoes? Sure. Will I order my own next to a greasy hamburger? Probably not. Of course, the caveats are when such things are at places so good that eating there is more of an experience than a meal. Kind of like the difference between eating a burger at McDonald's and a burger from Farm Burger. In that instance, I would both eat and enjoy my burger and fries.
Just not every day.

My real point is that this is ground zero. Kids who are overweight don't lose weight just by being admonished every time they reach for cookies. Some hard lines have to be drawn in the sand. And the grocery cart. Like, if anyone in the house is the type that can't say no to Oreo cookies or mojo potatoes, neither of those should be in the house. If anyone in the house is the type that has a slow-as- molasses metabolism then foods and drinks that aren't nice to them should stay on supermarket shelves for the most part.

At least, that's how I see it. For everybody to win, somebody's going to have to take one for the team.
And I know, there's always this argument where folks say, "Why should we punish our thin/fit/ideal-weight/healthy kid just because the other is overweight?"

My answer to that is simple: "Because that's how it has to be."

Some don't say that at all. Instead, their response might be to "just let kids be kids" and "if they exercise and run and play they'll grow out of it." This might be completely true-- and often is. But the problem is that the food relationship doesn't go away. That prepubescent pudge might melt away at first, but if mojo potatoes don't cause you to cringe a little bit by the time you turn thirty, that pudge will return just like a Jedi.

So I ask my patients about those food relationships. I ask who is up in that house and what's up with them and their health/body situation. Is Jack Sprat your husband? Meaning, is your spouse a hundred pounds soaking wet? And if so, does he or she do the grocery shopping? Whoever that person is and whatever their situation, that person has to get on the same team as you. Be willing to eat smaller portions with you and forgo certain foods being in the house to help you win.

That is, until your relationship and body shifts enough to make you feel like mojo potatoes aren't even worth it. So much so that seeing them on a platter before you does little to affect you. But see, for a lot of people, that kind of shift never occurs-- especially if they are starting from a place where food is synonymous with love and comfort.

It's a hell of a lot easier to shift your food relationship just a little bit than a whole lot. And square one for food relationships starts with the person doing the feeding....and how far she is willing to shift her own relationship first.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from "Reflections of a Grady Doctor", Dr. Manning's blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals' privacy.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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