Surf & turf and a side of asparagus, lobster bisque, smashed potatoes, and an unlimited bread basket, with cocktails and wine, and tiramisu if there’s room.

Most people don’t eat like this all the time, but how many restaurants are filled every night with rooms full people eating exactly this? Many of my patients may eat like this (or something very similar) multiple times a week.

If you want to drastically increase your risks for gout, acid reflux, severe sleep disruption, brain fog, stress intolerance, high cholesterol, high blood pressure, weight gain, and diabetes, there could hardly be a better recipe than the typical business dinner. Here’s the physiology: 1. Red meat, shellfish, alcohol and asparagus are high purine foods that elevate uric acid levels in the blood, increasing the risk of gout, a painful inflammation of joints, especially the first joint of the big toe. 2. High volume, high fat, and alcohol: All of these delay gastric (stomach) emptying, and may loosen the lower esophageal sphincter, making it easier for stomach acid to escape upward, causing heartburn, chest pain, even shortness of breath. 3. Late and prolonged eating: with an already sluggish stomach, finishing a meal within two hours of going to bed makes it even more likely that the stomach will still be relatively full when lying down, sloshing acidic stomach contents right up against that loosened sphincter in the horizontal position, causing painful night time waking, disrupting sleep and negatively affecting mood. 4. Alcohol itself causes neurologic changes that interfere with sleep, even though it may feel initially sedating. It also increases nocturia (getting up at night to pee), can worsen sleep apnea, and is a mood depressant in itself. Taken together, the compounding consequences of the business dinner make it a formidable enemy of health for many executives.

Now add frequent and often international travel with chaotic jetlag, the stress of high pressure, high stakes business transactions, responsibility for whole workforces of people, and disconnection from family, plus emails, voicemails, text messages, and all manner of 24/7 media demanding attention, energy, and time, all finite and precious human resources. It’s a wonder I don’t witness more heart and panic attacks than I do.

Despite these risks and challenges, though, many of my patients actually do and feel fine. They report high meaning in their work, enjoyment from connecting with colleagues (though nobody tells me they love those dinners). They find time to exercise on the road and at home, manage healthy eating, and get good enough sleep in other ways.

Or so we all thought, until the pandemic hit.

My practice closed along with the rest of the country for about 2.5 months in spring of 2020, and the rest of the year and beyond, most of my patients worked from home. Not surprisingly, and also a little shockingly, many of them showed marked improvements in standard objective biometrics when they came for their annual exams that year. BMI, body fat, blood pressure, and cholesterol fell, often precipitously. All of a sudden healthy behaviors that required heroic effort became almost as easy as rolling out of bed. With their long daily commutes eliminated, people could now make–had–time to exercise…and they wanted to because they weren’t mentally exhausted all the time. They could pace about their home office while on Zoom, maintaining energy and engagement. No more international travel, no more business dinners. Their environment and circumstances suddenly and significantly eliminated all kinds of friction on the path to healthy habits. And more importantly, they felt so much better, because they were sleeping more and better, rushing less, and spending more quality time with people they loved. It’s not rocket science–they had their lives back. [Note: I understand that I’m writing about an extremely privileged population. Please know that this awareness is not lost on either my patients or me, and we talk about it candidly.]

Today, frequency and distance of business travel approaches prepandemic levels. Typical work practices are resuming, with some consideration as to their net benefit, but maybe not a lot of action to experiment with or create new, more optimal models of workflow and interaction. In my office, I see patients’ stress levels rising again, weight coming back on, and an overall sense of bewilderment and resignation at it all.

As I write this, I feel a dense tangle of frustration, exasperation, empathy, impatience, protectiveness, and an urge to throw or slam something. Really I feel kind of rageful, actually. Existing disparites of access to resources, autonomy, security, and overall health and well-being widened and intensified dramatically through the pandemic. It makes me ashamed of humanity. How is it that my patients and I–people with agency, autonomy, knowledge, and power–can feel, and actually be, so powerless to change the systems that make us all, privileged and not, so f*ing unhealthy??

I have no concrete or actionable suggestions for how to make things better.

Sometimes I fantasize about going to these business dinners with my patients, like a chaperone. But rather than policing their choices, the point would be to make it safe for everybody to admit that they don’t necessarily want to be there, doing this conventional thing that social norms dictate. Based on years of conversations in the privacy and intimacy of the physician-patient interview, I feel peer pressure operating at the same intensity, and with just as high social consequences, as when we were all adolescents. It’s fascinating and depressing, like a black cloud that everybody feels, nobody acknowledges, and everybody suffers from in collective isolation.

What would it take for these deeply rooted cultural norms, ones that harm us all, to shift even a little? It’s a question I ask myself every day, in multiple domains. I get agitated and hyperventilate at the glacial pace of change. And then, usually, I can take a deep breath. I call on wiser voices than mine to get through.

I know there are people out there bucking the norm, challenging the status quo. I look for that spark in my patients, and I try to fan it, ignite it further. That’s the little good I can do, I guess. Maybe our little fires will one day light the way to bigger change.