A pinch of salt

By Sadiqua Sadaf, MBBS, India, & Amy Yu, MD, Johns Hopkins Medicine 

Being an observer in a system that’s almost entirely new to you offers a unique vantage point, one that allows you to see things that are invisible to the native eye. While I shadowed the hospitalist service at Johns Hopkins, I noted a major difference between the system here and back home in India. While rounding one morning, the nurses told my preceptor about a “difficult” patient with fluid overload that wasn’t responding as expected to the planned diuresis. We pulled up the chart to review their general condition, medications, diet orders, and input/output graphs. Nothing seemed out of the ordinary—they were receiving the appropriate dose/frequency of Lasix and had a fluid and sodium restriction order in place with a heart healthy diet to boot.  

“What are we missing?” my preceptor thought out loud as we stepped into the patient’s room. There, on their breakfast tray, was the answer—a can of diet soda. The orders were being followed with “a pinch of salt.”  

This led me to rethink the very idea of “hospital food” and how it evokes a different picture depending on where you are in the world. Hospital food back home is synonymous with a “healthy diet”—freshly cooked but very bland. Indian culture places great emphasis on diet as an integral part of healing, an order from the doctor that cannot be challenged. But I realized after this patient encounter that such norms aren’t universal and learned how the type of hospital food and patient attitude towards it can pose unique challenges to in-patient recovery. I spent the better part of that day looking up the ingredient list of the staples available in the hospital pantry. Every one of them included the usual suspects—sugar, salt, and high fructose corn syrup—an extension of prevalent cultural norms in the U.S. 

“I hate it here, doc. I can’t eat or drink like I want to. I feel like I’m in prison,” the patient said. What followed was an eye-opening conversation between doctor and patient. Instead of telling the patient to follow the diet as directed, my preceptor engaged them in discussing their dietary challenges. Calmly and with a lot of patience, the doctor tried to strike a balance between the patient’s autonomy and the medical need for a special diet. The preceptor also acknowledged the demerits of the available options at the hospital. The patient was momentarily pacified but expressed frustration over the lack of healthy food at the hospital of all places.  

 Here’s what I took away from this experience:   

1. Setting the standard 

Hospitals should be places of healing where we set standards for health and well-being that are meant to be modeled by patients even after discharge. Cutting out processed food from hospital cafeterias sets a high standard for hospital food so that diet orders placed in the system aren’t taken with a pinch of salt at the bedside.  

2. Patient attitudes 

What patients can and cannot eat at the hospital sometimes evolves into a question of autonomy and personal freedom that sometimes creates roadblocks to smooth recovery. It’s important to assess these challenges and identify ways for patients to balance personal choices about what to eat versus their clinical need to eat very healthily. 

3. Nutritional counseling  

While dieticians play an integral role in counseling patients about the need for a healthy diet, it’s equally important for this to be reinforced by the physicians in their discussions about goals of care. Having their doctor reiterate this need underscores the link between eating healthily and staying healthy in the patients’ minds. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.