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Vegetal Memories: A (Personal) History of Feeding Tubes
Some thoughts on food intimacy and clinical nutrition
It happened all too quickly. A hasty, confused phone call. Twilight charter to India. Stringy black-grey hair shaved for surgery. A brain stroke left my grandmother partially paralyzed, somehow defeating the gregarious matriarch beloved to Tatachar Compound, the urban village where she raised my father and his two brothers.
She ate soupy rice in the early weeks but it wasn’t long before her physical therapy plateaued and her regimen of gentle foods gave way to diet by nasogastric tube. It seemed perverse for a woman known to entertain. Feasting forms the thread of India’s social fabric, and my grandmother always did her best to uphold tradition from chai with Lily pedamma (my great aunt) to weekly luncheons with her former colleagues (grade school English teachers).
Her once-vibrant eating and socializing… reduced to a ritual of medical formula.
In witnessing my grandmother’s nursing care and formula feeding these past four years, I wondered how we heighten suffering when we’re disassociated from how we normally eat our food.
Bringing nanama to physical therapy in 2019
To answer this question, I began with medically-tailored meals and how they’ve evolved with the particulars of culture and geography. The ancient Hindu Vedas describe 67 medicinal plant applications that become the Ayurvedic diet by the 2nd century. When the spice craze swept Europe (leading Portugal to lay siege upon the southern tip of India), apothecaries celebrated the miraculous cure of gout by adding turmeric and pepper to meals. Leaf through a Belgian friar’s cookbook in the 13th century and you might find a “potio ad physico... chicken, lard, bone marrow, radishes, oil, and honey.”1
Simple, herbal meals forged the humble union of pharmacopeia and diet.
Advances in clinical nutrition appear around the late Middle Ages. As surgeons standardized previously crude methods of amputation, so too grew a belief that nutrition was “necessary to prepare the body before operations, and thereafter to promote wound healing.”2 In England, inappropriate nutritional care even became legal cause for a patient to sue a surgeon.
Insane asylums stood at the vanguard of artificial food introduction. One of the earliest examples I discovered of enteral delivery (devices passing food directly to the stomach/GI tract) appeared in an 1862 issue of the American Journal of Insanity where a Dr. Luther Bell heralded the new naso-esophageal prototypes. Others like Clifford Beers, founder of the first outpatient mental health clinic, questioned whether feeding tubes could promote effective healing if they separated patients from savoring natural flavors and textures.3
By Beers’s time4 we had deepened our molecular understanding of macronutrients. Nutrition morphed into a medical science with engineers from Chrysler and the Henry Ford Hospital designing food pump prototypes. Businesses like Ross Labs (acq. Abbott in 1964) began mass-producing formula. Beers and other mental health reformers viewed this progress favorably, but worried that food delivery technologies reconstituted natural food for industrial mass consumption. They considered formula and tubes devoid of the social joys of eating: “feeding is taken out of the realm of daily life and becomes part of the medical system.”5
My grandmother on her 3-times daily diet of fibre-free Jevity is a muted, 20-pound lighter version of herself. Once surrounded by steel bowls of bruised fruit and curry dishes in a trafficked dining room, I observed her new eating atmosphere on a recent trip to India. A sparse bedroom of syringes, linens, static television, a plastic sunflower nightlight, and a discolored tube snaking from her stomach.
I bring up eating atmosphere because many elements make up the ritual of eating. According to design theorist Christopher Alexander in A Pattern Language, the eating atmosphere must consider the space, utensils, and lighting; “some rooms allow people to eat leisurely and comfortably while others force quickness and a desire to leave.”6 The meal itself and one’s company matter too. Our eating elements can bind in “common rejoicing” and without them, we feel unsatisfied and unanchored.
1 in 3 patients experiences malnutrition in the hospital eating atmosphere. Many of them are fed like my grandmother from a menu of 100+ enteral formulas. A nurse appears at their bedside with a measuring cup and bag of cloyingly sweet formula. The feeding process begins with purification. Tube ends are swabbed with warm water and hydrogen peroxide, pinched for good measure to release any clogging. The amount of feed is calculated against a review of vitals. Finally, the opened tube receives a dose and is washed down with water.
When I visit, a young nurse pats my grandmother’s hand that frailty has left rivuleted with electric blue veins. She smiles warmly at me while dosing the formula. Her dimples are patient and knowing.
The resurgent interest in food/nutrition as medicine has largely ignored inpatient experiences.
We’ve treated feeding tubes and formula like an ugly afterthought, while rewarding the companies who’ve sexed up nutrition with visuals of bountiful produce and personalized, tailored meals.
Why haven’t we had a simultaneous push to improve enteral feeding? Formula, while unregulated by the FDA, is reimbursed by calories (creating some strange incentives for hospitals to jack up calorie content). Patients frequently regurgitate and pull out corrosive tubes, yet no one has redesigned the feeding tube since the 1960s. It presents an odd, greenfield opportunity particularly with the long-standing knowledge that nutritional interventions at the point of care reduce mortality rates by 30%.
But we’ve avoided feeding tubes because they confront us with the raw condition of suffering. These serpentine, unattractive technologies - while meant to improve nourishment and sustenance - detach us from the very essence of the human experience. As David Wong Louie writes of his enteral feeding experience in Harper:
With the G-tube, I did not eat — I fed the tube. My mind did not equate the formula with food, as other patients do — how could I confuse the two? Goose in Hong Kong is a meal, not a feeding; the table is laid with utensils, not a syringe; one dines, not feeds… now I’m a hundred percent Fibersource via the G-tube.
Like Louie, my grandmother still reveres the dining table as an expression of life. But her feeding technologies show our profound disconnection between food, nourishment, and the human experience. A disconnection that deteriorates the already fragile condition of someone who is suffering.
It’s a reminder to us that health tech comes with both advancement and loss. For those of us who build, we are called to strike a balance between communion and innovation. Always remembering our responsibility to progress and be unafraid of even the most unsightly technologies, but to do so without losing our mutual, gentle human spirit.
Angela Montford, "‘Brothers who have Studied Medicine’: Dominican Friars in Thirteenth-Century Paris," Social History of Medicine Volume 24, Issue 3 (Dec 2011): 535–553.
Madeleine P. Cosman, “Medieval Medical Malpractice and Chaucer's Physician.” NY State Journal of Medicine Volume 72, Issue 19 (1972): 2439–44.
Norman Dain, Clifford W. Beers: Advocate for the Insane (University of Pittsburgh Press, 1980), 32.
If I’m honest, Beers’s ideas were more steeped in poetics than an understanding that impaired bodies accelerate skeletal muscle breakdown. But other peers advanced nutrition x biochemistry like Elmer McCollum, the famed public health advocate who wrote The Newer Knowledge of Nutrition (1918), and Adolf Windhaus who received the 1928 Nobel Prize in Chemistry for his revelations about vitamins.
Sara M. Bergstresser and Erick Castellanos, "Feeding versus Artificial Nutrition and Hydration: At the Boundaries of Medical Intervention and Social Interaction," International Journal of Feminist Approaches to Bioethics Volume 8, No. 2 (Fall 2015): 204-225.
Alexander, Christopher. A Pattern Language: Towns, Buildings, Construction. New York: Oxford University Press, 1977, pp. 1253.
Opinions my own and do not reflect the views of any affiliate organizations.