"Pablo" had a heart attack. Again.
Two or three years ago he found himself in the ER with excruciating chest pain and shortness of breath, did a lap through the cardiac catheterization lab and ICU, then went to the general cardiac floor and ultimately home and back to his normal life. That's too bad, that latter part, because "normal" for Pablo was a diet of the likes of McDonald's and KFC together with a general disregard for medicine, exercise, and doctors. So now he's had another heart attack and repeated the same process all over again, except, we hope, for the return to his previous "normal" life. Combined, Pablo now has eight stents in his heart, and one foot on the proverbial banana peel.
But this time it seems he was scared straight. Well coached while in the hospital, he could recite his medication regimen almost completely correctly from the first day I saw him at home, he had an overall good sense of what a "heart healthy" diet was, and he knew exactly when he needed to see each of his doctors. He wanted a medication list written in a particular way that made sense to him and would help him manage his pills; I can take direction, and carefully complied with his request. He's done beautifully with his medications ever since. He showed me the cans of vegetables that he had purchased, and with raised eyebrows asked if he had made good choices. Frozen would be better than canned, I explained, but if he carefully rinses the canned products before preparing or eating them he should do fine. He agreed, and has followed through. He has kept his appointments . . . except for the one with me that his missed today, however, I found a tidy note taped to his door telling me that he had needed to go to the hospital to see his cardiologist, whose name he amusingly misspelled. Yes indeed, this time Pablo is making an effort. "I didn't take care of myself before," he has told me, "I eat all the grease."
Looking out the window of his small apartment I understand the temptation. There are not more than five or six feet of clear walking space in his home, but as Pablo shows me where to hang my coat and rolls an old desk chair over to the table so I can sit down he is noticeably short of breath. He feels fine when he's resting, he says, but when he tries to "do anything" he feels "not so good" and needs to rest again. I tell him that this is normal in the early period after a heart attack, and that he should "listen" to his body, resting as soon as he begins to feel tired, and then resuming activity when he feels better. In this way he gradually will be able to do more and more, and won't overtax his healing heart in the process. I tell him he is taking medication that slows his heart and decreases its workload so it can heal, and while this, too, can make him tired, he won't need it forever.
I don't know how Pablo obtained those canned vegetables, as the nearest grocery store is six blocks away. Given that Pablo becomes tired and winded just walking around his little apartment it's hard to imagine him somehow making his way downstairs, outside, and to the store, and then carrying groceries home. But from his apartment I can see McDonald's right across the street, Burger King around the adjacent corner, a fried chicken place, and a number of pizza joints. The heart of a strong Asian community is just a few blocks away, complete with many restaurants that deliver (sodium laden) traditional foods.
And today while I was waiting for the elevator in Pablo's building I glanced over my shoulder and saw these:
Yep, two vending machines full of sugar, salt, and fat. The beverage machine does have one offering of bottled water, which probably is that last thing that the low-income residents of this subsidized senior housing building need, having both little money and running water in their apartments. Otherwise the only options here are nutrient-poor, high risk selections.
It's little wonder Pablo was "noncompliant" after his first heart attack.
"Zelda" is another of my patients who lives in the building. A diabetic with high blood pressure and diseased arteries, she developed a leg wound that wouldn't heal. It became infected, and by the time Zelda went to the ER she had developed gangrene and her leg needed to be amputated above the knee. Now she crashes into walls and furniture just trying to learn to maneuver her wheelchair around her apartment; I can't imagine her managing on the street. Yet, like Pablo, if she is hungry in the middle of the night, or her daughter is delayed bringing groceries, Zelda's only option is to wheel herself to the elevator and ride down to those vending machines.
Sugar, salt, and fat: All addictive, and all exactly what someone with diabetes, high blood pressure, and vascular disease doesn't need.
And there's "Dolly," a somewhat confused little dynamo of a woman who went to the hospital last fall with some gut issues. Those now have resolved, but in the course of her workup a Vitamin B12 deficiency was discovered, and I see Dolly regularly for vitamin injections. These are stored in her refrigerator, and every time I remove the vial I notice that there is precious little food there. There is a lunch program in the building where residents can buy hot lunches five days a week for little more than pocket change, and not only does Dolly like those, but also she seems to have gamed the system such that she often is able to take home "extra food." Her son is attentive and often there; I don't believe he will let her starve. But my sense is strongly that his resources are limited, too, and that Dolly, who needs written reminders posted in order to remember to turn off the water, is unlikely to be able to hop on the bus to go shopping.
Of course, neither are Pablo or Zelda, and, very probably, many of their neighbors.
But there's always those vending machines . . . full of nothing that nourishes, ingredients that heighten health risks, and untold preservatives and other additives and chemicals.
I stood outside the building this afternoon, counted its floors, and did a little quick arithmetic: I'm sure there are over 200 apartments there, each occupied by a low-income senior or couple, most of whom probably have health issues, and all of whom would benefit immeasurably from decent nutrition. Yet apart from the five weekly lunches, a bus or taxi ride to a grocery store, and/or the benevolence of friends or relatives, these seniors' option for meeting a most fundamental need is vending machines full of, to put it kindly, junk.
We can do better.
After visiting Zelda today I stopped by my house to pick up my own lunch and let my dogs out for a few minutes, and in the short time I was there noticed in my own kitchen many options that would be vending machine friendly, nutrient rich, and consistent with most therapeutic diets. Things like these:
In that photo are instant organic oatmeal packets with such additions as nuts, dried fruit, flax, and pumpkin seeds, with no sodium or added sugar. There are small packets of dried fruit and whole grains, the latter having some sodium but reasonable amounts when portioned out correctly. The cans contain sparkling fruit juice.
I can drive, shop, cook, and emerge unscathed from dietary indiscretions more or less unharmed, so I've not made an effort to stock my kitchen with easily prepared nutritious foods. Imagine the collection I could gather if I did!
If vending machines can dispense cold pop and sweetened iced tea, then they can dispense juice, yogurt, cheeses, healthy milks (I prefer almond milk to cow's milk for many reasons, but any milk is better than pop!), and other nutritious selections. Instead of candy and chips they can offer whole, dried, or single-served canned fruits, low sodium single-serve soups, nuts, even small amounts of dark chocolate, and more. If a vending machine can dispense ice cream bars, then it also can hold single-serve packages of frozen vegetables and lean meats. And so forth.
But there's more. Here's the space around the building where Pablo, Zelda, and Dolly live:
There has been maintenance work on the exterior of the building, hence the damaged lawn and remaining construction fences and equipment. But what I see is massive space for residents to plant gardens. Imagine raised beds, with seating among them, both for tired gardeners and for other neighbors who might stop by to chat while enjoying the sunshine.
And look at this:
This is the side of the building, and those long balconies have a direct southern exposure. Picture pots of tomatoes, peppers, herbs,and other crops, with beans and other vines growing on the railings.
In short, the answer to Pablo's, Zelda's, and Dolly's nutrition problems is right where they live: Replace the "junk" in the vending machines with nutritious alternatives, turn much of the lawn into a garden, and put pots on the balconies.
Many years ago I visited "Theda," who suffered from "cardiodiabesity," that is, the combined ill effects of cardiovascular disease, diabetes, and obesity. One day she was thrilled to have three or four large bags of groceries sitting on her table when I arrived, delivered by volunteers from a local charity. However, she asked me to go through them and remove anything she shouldn't eat, explaining that she could give those things to neighbors and wanted to be sure she was having the right things herself. From all those bags I was able to select only a handful of items that would be safe for Theda, and sadly had to advise her to give the rest away. She agreed far more readily than one might have expected, being serious about not doing anything more that could damage her health.
Over the years I've wondered about those volunteers, who no doubt believed they were doing something helpful and good when they delivered those groceries. How helpful it would be if the public health department provided guidelines for food pantries and other charitable organizations and their donors so that better selections could be offered to their clientele, with less waste and fewer health problems down the road.
And what if instead of delivering unhealthy items, some of those volunteers helped people like Pablo, with his fatigue and shortness of breath; Zelda, with only one leg; and Dolly, with a diagnosed nutritional deficit and cognitive limitations as well; what if those volunteers helped such seniors plant and tend their gardens? Churches that collect donations for food pantries might also collect commitments to donate hours for weeding plots and staking tomatoes, and students who need community service hours could pitch in as well, helping with shopping as well as gardening. Of course many residents are robust and would be able to tend their own gardens and help their neighbors, too.
To some extent after his first heart attack Pablo probably didn't fully believe that whether he had a burger at McDonald's or troubled to make his way to the store to buy lean meat and prepare it at home himself made much difference, and McDonald's certainly was easier. Zelda likes her "regular pop, not diet" and is an admitted junk food junkie, but no matter her preferences those nutrient-poor, chemical-rich options are all that's readily available to her. And I wonder if Dolly's nutritional deficit would be as severe if she had regular access to the makings of a well balanced diet.
Everything necessary to effect positive change is right in the neighborhood, and mostly is in that building and on its grounds. Contracts with suppliers for the vending machines would need to be renegotiated, but otherwise much reduces simply to repurposing space and redirecting the efforts of well intended people. This isn't rocket science; it's little more than a matter of awareness, organizing, and enlightening.
We can do this. Solutions to this problem and so many others, or at least ways to make bad situations better, often are contained in the problems and situations themselves. And therein lies the key to how
We Can Do Better.
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