On a beautiful, unseasonably cool late July day, the 65-year-old Bronx woman is the first of about a dozen patients scheduled to meet Andrea Plunkett, a registered dietitian, on the 6th floor of the SBH ambulatory care clinic for a 45-minute nutritional assessment. Most of the patients Plunkett will see today suffer from a chronic disease – obesity, diabetes, cancer cardiovascular or respiratory disease – or are on the cusp of one, such as a pregnant woman with gestational diabetes and a pediatric patient with pre-diabetes and a BMI over 35 – and have been referred by their physician with the goal of improving their health.
“Obesity is a major problem, especially here in the Bronx, and it leads to a number of medical issues, including metabolic syndrome,” says Cecilia Moy, clinical nutrition manager, SBH Health System. “We explain to patients in these meetings why it is important to make changes and how to go about doing it With those patients who are willing to make changes, the chance of achieving their goals is very realistic and reachable.”
Moy has been effective in spreading the gospel about the importance of nutritional counseling in combatting and preventing chronic disease to both primary care providers and patients. She can point to, as a result, an increase over recent months in the number of nutritional referrals from physicians at nearby clinics and, as importantly, a reduction in the number of patient “no shows.” Both audiences, she says, are beginning to see the importance of nutrition on overall health. She further credits the hospital’s decision to move outpatient nutritional counseling to a centralized site with more flexible hours for playing a role in this trend.
In the fall, a pre-surgery nutritional program will begin. Initiated by Moy and Dr. Robert Karpinos, director of perioperative services and medical anesthesia at SBH, it was created with the goal of improving patient outcomes in surgical procedures and reduce postoperative hospital stays.
Cutting through barriers
Dr. Rajan Gurunathan, chief, Division of Medicine, Department of Medicine, is an enthusiastic proponent of the nutritional effort. “Food insecurity has a major impact on our patients and we recognize the role nutrition can play for patients with chronic conditions,” he says. “We’ve made it a priority and are trying to encourage appropriate nutritional counseling for these patients.”
Many of the patients seen by the dietitians, including Diaz, who was recently hospitalized, take numerous medications for their chronic conditions. Losing weight can often help reduce their reliance on meds. Diaz is hopeful that by eating better she can also eliminate the feelings of nausea she suffers each morning. “Just smelling the food can make me throw up,” she says.
The cards are often stacked against area residents. The lack of access and cost can present a formidable barrier for many Bronx residents to eating healthy. Much of the Bronx, Plunkett acknowledges, is a “food desert,” where fast food restaurants overwhelm in numbers those markets selling fresh fruit and vegetables. Her job, as she sees it, is to show her patients that within this environment change is possible.
She says she can quickly access a patient’s readiness to change. “The first question I ask is, ‘What brought you here today?’ and ‘What’s preventing you from changing?’ ” she says. “Their answers tell me a lot.”
Diaz seems motivated to make that change. Ideally, she says, she would like to lose 50 pounds. The dietitian begins by asking her what she’s eaten in the last 24 hours. For breakfast, Diaz says, because of her nausea, she had coffee, with sugar and cinnamon, and evaporated milk. She says she skipped lunch and had chicken and pasta and half a soft drink for dinner.
Plunkett explains to Diaz that skipping meals, counterintuitively, will sabotage her weight loss efforts as it slows down her metabolism, adversely affecting her ability to burn calories. She teaches her to be mindful of how much she’s eating by showing her a “portion plate” with plastic food models – ½ of the plate for vegetables and fruits, ¼ for grains (such as beans) and ¼ for lean protein (such as chicken or fish) – and cups and measuring spoons to demonstrate proper serving sizes. She discusses the importance of replacing certain foods – such as white rice with brown rice and green apples (which have less sugar than red apples) for sweets – and how healthy snacks, like almonds and bite-sized pieces of raw vegetables have fiber that will help to control or curb her appetite. She gives her a quick tutorial on how to read food labels.
The dietitian recommends a daily diet of 1200 calories and offers suggested menus and a general tip sheet on losing weight (e.g., eat only in a chosen place, such as at the kitchen table, and not in the car or the bedroom or in front of the TV). The dietitian offers suggestions that will hopefully reduce Diaz’s bouts of nausea.
“You can’t expect to lose 50 pounds in one month,” Plunkett tells her. “You need to take small, gradual steps. Try to lose one pound per week.” She schedules a follow-up meeting in six weeks – after all, it takes time to make behavioral changes. Plunkett will document her meeting with Diaz and forward it to her doctor. The patient leaves hopeful that there is light at the end of the tunnel.