2015 Physician writing contest winner: Jeremy

Jeremy had lived his whole life in a desert when I first met him for his annual checkup at St. Christopher’s Hospital for Children. Fifteen formative years of this life and their effects on Jeremy have been toxic. As I reviewed his chart I was heartbroken reading over his past medical history trying to imagine what he had endured, yet not surprised by the predictability of his diagnoses rooted in a life lived in a desert.

Chart review. Age five. ICD code 327.23. Significant obstructive sleep apnea. Tonsils and adenoids removed. Age eight. ICD 312.0. Child being bullied. Transferred to new school, mother concerned about depression. Referred for therapy.

Age eleven. Groin pain. Radiograph shows slipped capital femoral epiphysis, ICD code 732.2. Open surgery on hip with metal pins placed for fixation. Age thirteen: diagnosed with hypercholesterolemia, vitamin D deficiency and pre-hypertension. The ICD codes kept stacking up like grains of sand falling from an hourglass inevitably shortening Jeremy’s life.

Food deserts and poverty

The desert that Jeremy lives in is not that of the glamour and excitement of T.E. Lawrence’s Arabia, but one that continues to damage tens of millions of children in the United States, and one that contributes to the unconscionable possibility that the present generation of children in the U.S. might live shorter, sicker lives then their parents for the first time in recorded history.

Jeremy’s home and school reside in Pennsylvania’s First Congressional district, a few blocks from our hospital. This district is the third-most-impoverished for children in America. It is the second-most food insecure, with almost half of all families running out of food, or having to make the unimaginable choice of heating their home or eating.

Jeremy lives in a food desert. A desert where fresh, affordable food is out of his reach. Something that is taught about in health class, but at home, he finds only calorie-dense, inexpensive processed foods.

In the food deserts of Philadelphia, in the most concentrated areas of poverty, childhood overweight and obesity rates exceed 50%. Jeremy at fifteen weighed 240 pounds and like many in his family was on a predictable course for the development of diabetes and it’s crippling consequences.

Jeremy told me he was scared. His grandfather had his leg removed from diabetes and his mother had recently been started on insulin. Jeremy did not like shots. He tearfully discussed with me the powerlessness he felt dealing with his weight. He saw the inevitability of a diabetic future that many in his family sensed.

He did not want this to happen to him. He wanted help. He wanted to stop the sands of time, and live a healthier life. The grains of sand had buried too many in his family already.

NEXT: "A prescription for food"

A prescription for food

Social determinants of health, (where people are born, grow up, live, work, and play), are now thought to contribute up to 80% of health in the United States. It’s well known that your zip code is a more important factor in health then your genetic code. No other health condition is more evidence of this than obesity.

One of the tenets of motivational interviewing is assessing a patient’s readiness. Jeremy was ready, engaged, and was old and insightful enough to be able to take matters into his own hands, with some help.

Obesity, like many chronic illnesses, is multifactorial, but can be broken down to the basic equation of more calories in than out. Unfortunately, this equation is stacked against children like Jeremy who live in poverty. Children who can’t find a safe place to play stay inside, snacking, their faces reflected on computer and video game screens. Their parents may have to take two buses to the nearest grocery store, past dozens of more convenient corner stores, just to get fresh fruits and vegetables.

The cost of obesity in America is estimated at $93 billion annually and more than 20 million Americans suffer from diabetes, a four-fold increase since 1980. The emotional cost to Jeremy was immeasurable.

I could not write a prescription for Jeremy to lose weight, or could I? Could I put together a treatment plan for Jeremy, using resources both in our community and inside our own hospital’s walls? It started with a prescription for food.

Since 2011, in response to the food insecurity that our families face, our hospital has collaborated with an organization that brings low-cost, farm-fresh foods into our office weekly coupled with a demonstration kitchen to introduce families to foods that may be foreign to them.

Kale, cabbage and beets overflow the “Farm to Families” boxes, surrounded by the more familiar eggs and cheese. Jeremy and his family became Farm to Families regulars but this wasn’t enough.

Using his cell phone, I helped Jeremy connect with the USDA’s choosemyplate.gov website that helps teens plan, analyze and track their diet and personal physical activity goals. Jeremy was eager to embrace these changes, and help his family members do the same, but he needed one more intervention that had eluded him most of his life. A safe place to be more active.

Health insurers are well aware of the cost of childhood obesity to society and their bottom line and many have become allies in this battle. A quick check of Jeremy’s insurance, as well as his zip code, and I was able to find a YMCA close to his home that he could join free of charge. He had walked by this YMCA for years, staring at the modern exercise equipment, but never thought that his family could afford a membership.

We had several follow-up visits and his weight slowly came off, and then, discouragingly, I didn’t see him for over a year.

When I saw that he was finally back on my panel after a year’s absence, I was worried that all the connections that we worked so hard to make may have been broken, and that he, like many other children lost to follow-up, had put back on the weight that he worked so hard to lose. I was quite wrong.

‘I did it for me’

Now seventeen years old, Jeremy looked at me expressively with pride:185 pounds. He was in great shape and that brooding adolescent that I first encountered morphed into a confident young adult teeming with life.

“Where you been?” I asked trying to discover why he hadn’t come to his follow-up visits. “You know, school, working”, he answered. “I got my mom to come to the Y as well. She’s doing better.” He had become her health coach as well. “How did you do it?” I asked pointing to his flattened abdomen. “I did what we agreed to do, I did it for me, for my mom,” his maturity surprised me and his drive to combat a disease that had crippled so many in his family members and neighbors was palpable.

Jeremy’s trek through the obstacles to good health brought him to a personal oasis that eludes far too many children and adults in the United States. Through coordinated care and connecting with each patient, we can slow down the sands of time and help each patient, each neighborhood, and help each Jeremy find a path to a healthier life.

Daniel Taylor, DO, FAAP, FACOP, is an associate professor at Drexel University College of Medicine, director of Community Pediatrics and Child Advocacy at St. Christopher’s Hospital for Children, and developer of Cap4kids. He lives in Philadelphia, Pennsylvania.