It is not much past seven in the morning and I am on my morning pre-rounds, pushing my rolling computer from room to room to examine patients, review their lab data and update their medical plans. I enter the room of one my sleeping patients. With each passing day, I’ve watched his legs grow thinner and his energy wane. His body needs protein and calories now more than ever.
Several boxes of a liquid nutritional supplement sit on my patient’s tray-table. There are a variety of flavors — vanilla, chocolate, strawberry — just as I had ordered. Like many of the patients I see, he has what we call “protein calorie malnutrition,” which accompanies a range of conditions, from failure-to-thrive at home to critical illness in the I.C.U. The elderly and sick are more likely to lose their appetites and eat poorly, and at a time when the body is most dependent on good nutrition, it is betrayed by these symptoms. Untreated, the weak become weaker, the sick become sicker, and a terminal spiral ensues.
Supplement shakes like these, with confidence-inspiring names like Boost and Ensure, are marketed aggressively to consumers and health care providers alike as a healthful panacea for all those struggling to take in enough daily calories. The theory behind these drinks is simple and makes sense: They provide a dense and palatable form of calories that can be tolerated even by those who have poor appetite, no teeth, difficulty swallowing or any of the other myriad symptoms that accompany illness.
I pick up one of the colorful, cheery boxes and turn it over to look at its ingredient list. My eyes find the first and main ingredient: water. Then the second ingredient by quantity: corn syrup. There, farther down the list, is a milk-derived protein, and then, more sugar. The protein content is only 10 grams. The diminutive Greek yogurt I had that morning before work contained more protein and a fraction of the sugar.
A wave of queasy guilt comes over me as I think to myself, “This is how I’ve been treating malnutrition?” Beverages that contain refined sugars like these have been linked in many rigorous studies to metabolic derangements like Type 2 diabetes, heart disease and fatty liver disease. When I see patients in the office, I remind them at every visit to avoid these kinds of heavily processed and sweetened foods and drinks.
Food has the potential to be some of the best medicine. But not food like this.
As a physician, I need to be able to offer more wholesome and therapeutic options to my patients than what amount to synthetic sugary shakes with a middling amount of protein. Also upsetting is knowing that Medicare and Medicaid are footing the bill. And if the big food giants like Nestlé and Abbott and our hospitals aren’t working to provide more healthful alternatives, then practitioners and patients should work together to come up with their own.
I have a few ideas.
From thick style Greek yogurts to drinkable Kefir-style preparations, full-fat yogurt provides a high-calorie, high-protein base that can be flavored to any taste. Yogurt has the added benefit of being a probiotic, which have been shown in large, systematic reviews to protect again C. difficile infection, a particular risk for patients already receiving antibiotics. We have already seen one hospital significantly cut it’s rate of C. diff by serving yogurt to its patients every day.
For those who don’t like the taste of yogurt, or who are lactose intolerant, nondairy alternatives include almond and soy-based beverages, and high-protein, low-sugar options are readily available
In an even more ideal world, hospital food services would use yogurt or nut milks as the base for freshly made smoothies and add nutrient-dense items like avocado, berries, spinach or peanut butter. I admit, this is a tall order, likely to remain the realm of luxury and boutique health care facilities.
That said, I have already started recommending these types of smoothies to my outpatient clinic patients and even give them specific instructions and proportions. One of my greatest success stories so far has come with a young female patient who had been struggling with proper nutrition and chronic constipation. Spinach-yogurt smoothies are now a part of her daily routine and she is feeling better.
I recognize that there are economic and other forces at play that can hamper these goals. But even if the fresh smoothies I dream of never materialize on my patient’s hospital tray-tables, I will continue to spread my message one patient at a time.