United We Continue to Stand

When I cared for adults in an internal medicine practice in suburban Cleveland, I frequently observed a wonderful phenomenon. It was not at all unusual for patients to bring along their children and grandchildren, fresh from a prior appointment across the hall with their pediatrician. Beautiful, bright-faced, fresh-scrubbed, engaging, chubby, usually well-behaved, American children. The pediatricians’ well-intended recommendations on reducing the rate of weight gain continued to be unsuccessful, and my patients’ faces told me that the ongoing exhortations had become tiresome. If they knew how to fix this problem, they told me, they already would have.

Conversation shifted quickly to these new adult patients, who also could usually stand to make a few changes. Blood pressures and sugars rising, waist lines growing. Uh-oh, do you wanna dance at these kids’ weddings or what?

Enter “Your Health is on Your Plate.” Stop dieting, I said, and stop thinking about your weight. Shift your focus and eat more vegetables and fruit. Stop avoiding nutritious fat: eat avocados, scrambled eggs, olives, almonds, peanuts, anchovies. Deep-six the OJ and eat oranges. And berries. And apples, which are especially good dipped into peanut butter.

Stop buying breakfast “cereals.” Why do I put that in quotes? Because cereal is a synonym for grains, like millet or oatmeal or bulgur wheat. Lucky Frosto’s, Cap’n Sugar, Raisin’ Weight and Sweetest Bran are not nourishing whole grains. They are substitutes for dessert. If you wouldn’t feed your kid a brownie or a piece of apple pie for breakfast, then you would never feed your kids breakfast “cereal.” 

Well, you know the next part of this story. Patients returned to subsequent appointments with improvements all around, which was not the most surprising part. The crazy thing was that the children had, unexpectedly, experienced the same benefits. Pediatricians saw weight curves bending toward the normal range. Families felt more empowered and less hassled. And I saw those little bellies shrinking away with my own eyes.

A recent research study showed that attempts to teach self-care strategies to patients with early dementia (or “minimal cognitive impairment”) were largely unsuccessful, but that including a primary caregiver in the conversation made all the difference. The researchers called this teaching unit a “dyad,” referring to the two people (one the designated patient) who received the intervention. So if you struggle to remember important details about your shower, soap, toothpaste or nail clippers, it will not help for someone to sit down and go over it all again. But include the loved one who has actually assumed responsibility for providing assistance every day, and it may actually do some good. These results should not surprise you.

Successful lifestyle changes engage not just the designated patient, but also the individual who makes the majority of the lifestyle-related decisions for the family system to which they both belong. This is true of everyone in the family, but most especially those [like children and cognitively impaired elders] who have limited say in creating the environment of their home.

Who purchases and prepares most of the food in the family; schedules trips to the pool and soccer field; makes time for hikes or baseball games; takes the kids to the dentist; makes the annual school-physical appointments; chooses where to put the rugs and lights; decides who sleeps where, and what time is bedtime? Who issues instructions for baths, showers and toothbrushing? This person is key to the health of that family.

We human beings are social creatures, meant to operate in groups. A medical system that operates, intervenes and reimburses at the level of the individual will continue to struggle.

2 thoughts on “United We Continue to Stand

  1. Excellent point, Dr. Sukol. We need to focus on both our patients and their caregivers. This is important to keep in mind for both pediatricians and adult practitioners alike. This article reminded me of a great TED talk by Dr. Rishi Manchanda about the upstream factors of health.


    Also, I’m glad you mentioned the pediatrician’s recommendations to lose weight. I think it’s time clinicians stopped with these futile exhortations and instead gave their patients useful information that could actually help them achieve this goal.

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