I’d asked whether she was eating a lot of salt. Third admission in a year, I was going down her med list, and the question wasn’t on the list. It came out sideways, the way things do at the end of a long afternoon.
Same as regular. Like everyone.
Two grams a day is what I’d told her. First visit, second visit, printed on both after-visit summaries. She nodded each time. I don’t think she ever knew what 2 grams was, and I never checked, because the clinic was full and nodding looks like understanding when you’re already thinking about the next room. But “like everyone” meant she was eating out of a pot that fed five people. Nothing I’d said in a year had gotten within arm’s reach of that pot.
So I asked her the question I should have opened with. Who cooks at home? Her daughter. Two jobs, cooks on Sunday for the whole week, makes what her own mother made. Five people, one refrigerator. She’s a composite of patients I see, and every note I’d written on her said diet counseling provided. For a year I’d been prescribing into a kitchen I had never once asked about, then charting the result as nonadherence.
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I thought about her when I read the MUTTON-HF trial in JAMA Internal Medicine in July. Two hundred and six adults with heart failure at 2 Indian Health Service sites in rural Navajo Nation, randomized to usual dietary advice or 8 weeks of 2 prepared meals a day, built from mutton, corn, beans, and squash. At 90 days, hospitalization or an ED visit for any reason came in at 41 percent against 57. Heart failure hospitalizations, 3.8 percent against 13. Quality of life improved. Food insecurity fell. Blood pressure was lower.
The take everybody had was that culture matters, that tailoring works. That’s true and I believe it. But read what they actually had to build. They sourced from Navajo farmers and ranchers and cooked in a Native-run commercial kitchen. They supplied microwaves and mini refrigerators, and for homes without electricity, propane appliances and the fuel to run them. About 95 percent of participants had no mail delivery, so the team built a distribution network across the reservation with central and satellite pickup hubs, and sent community health workers to the homes of people who couldn’t travel to one.
The recipes are the part you can photograph. The rest of it is the trial. What they were really doing was making a place in a person’s life where the food could exist. Cultural tailoring is what got it eaten. Everything else is what got it there.
That’s the part I think we’re about to skip. Every health system I know of has a food-is-medicine deck circulating right now, and most of them fund the meals and stop. Nobody line-items the refrigerator. Nobody line-items the drive. And when the numbers come back flat, we won’t say the program was underbuilt. We’ll say the patients didn’t engage.
I want to be careful here, because I’m reading somebody else’s trial and I don’t work in tribal health. Two hundred and six patients, one Nation, 12 weeks of follow-up. We don’t know yet whether the results hold at a year, and the cost-effectiveness work is still ongoing. The study doesn’t settle the question. It simply exposes the infrastructure we often ignore.
But the clinical habit it exposes is not confined to the Navajo Nation. In August in San Antonio, produce sitting in a hot car for 40 minutes on the way home from a grocery store somebody drove past three dollar stores to reach is a physiology problem, not a willpower problem. I’ve written low-sodium plans for people whose only working appliance was a hot plate. I never asked. It wasn’t in the template, and the template is what I was documenting to.
What I got wrong for most of 25 years wasn’t the nutrition. The nutrition was fine. I was writing a prescription to a person and delivering it to a system, and I never looked at the system. Then I’d sit in a readmission huddle and talk about motivational interviewing.
So now I ask two things before I write a dietary plan. Who cooks. And where does the food live once it gets to the house. It takes maybe 90 seconds. Neither question is in any guideline I’ve ever been handed, and both of them change the plan more than 2 grams a day ever did.
So here’s my ask, and it costs you 90 seconds. Before you renew the sodium restriction on your next heart failure patient, ask who cooks and where the food lives once it gets to the house. Do it at the first visit, not after the third admission, the way I did.
Then put the answer in the note. Not buried in the social history where nobody reads it. Put it in the assessment, next to the ejection fraction, because it influences readmission the same way the ejection fraction does and we’ve been treating it as background information.
If enough of us document it, it stops being an anecdote and starts becoming visible in the numbers. That’s how the refrigerator gets line-itemed. That’s how the drive gets counted. And it’s the only part of this any of us can do on Monday without permission from anybody.
For too many years, I was writing a prescription to a person and delivering it to a system. The least I can do now is ask what system I’m delivering it into.
Shiv Kumar Goel is an internal medicine physician in San Antonio, Texas, who has spent twenty-five years in hospital medicine, the ICU, and functional medicine. He is the founder of Prime Vitality, a holistic wellness clinic, and TimeVitality.ai, an AI-driven platform for advanced health analysis.
Dr. Goel serves on the editorial committee of the Bexar County Medical Society, and his writing has appeared on KevinMD, in the San Antonio Express-News, and on Op-Med. He shares his clinical and educational work at drshivgoel.com, publishes on Medium and Substack, and hosts the Vitality Matrix with Dr. Goel channel on YouTube. He is the author of the forthcoming book Healing the Split: When Your Biology Is Fighting Your Biography.
