University of Pittsburgh School of Medicine, PennsylvaniaIt is a basic truth, well known to physicians and many others that the size of one’s body is an accurate reflection of how much one eats. As a physician specializing in caring for overweight and obese children, I know how difficult this is for many to accept. Telling overweight people that eating too much is the root cause of their problem is met with disappointment, denial, and even anger. Countless times I have heard parents tell me, “My son hardly eats anything,” or “We’ve tried cutting back on eating and it doesn’t work.” Some parents insist that some underlying metabolic disturbance is the cause of their child’s obesity. Explaining that a rare disease is an unlikely cause of the problem, and that even if it could be found, eating less would be at least part of the solution, is frequently met with skepticism. Metabolic diseases may lead to weight gain in a miniscule number of children. Many parents are convinced that their child is one of them.
Why is it so hard for some people to accept they are obese because they eat too much? Consider that I’ve never heard of a patient with lung cancer or emphysema deny having smoked too much. Nor have I even once heard of a patient with a sexually transmitted disease claim to be chaste, but obesity and its indisputable connection to overeating has much worse implications. The Catholic Church divided sin into two categories: venial or minor, and capital or deadly. Gluttony, together with lust, greed, sloth, wrath, envy, and pride, is among the latter. Different definitions of gluttony emerged in ancient times. Thomas Aquinas listed five ways to commit gluttony: eating too soon; eating too expensively; eating too much; eating too eagerly; and eating too daintily.1
In the Bible and other ancient texts there is little mention of a connection between gluttony and obesity. This is not surprising given that in ancient times not getting enough to eat was far more common than eating too much. Obesity was limited to a few of the privileged class. Gluttony was a sin not because it made one obese, but because it reflected an obsession with physical pleasure, presumably at the expense of one’s spiritual life. The contemporary definition of a glutton is someone who eats and drinks excessively, whether or not his behavior reflects an abandonment of the spirit. A modern glutton, however, has a stereotypic appearance that goes well beyond the basic definition: morbidly obese, stuffing himself with huge amounts of food in a way that is messy, selfish, and repulsive. Like the gluttons of Biblical times, the modern glutton is prone to neglect, perhaps not his spirituality, but other aspects of modern life. He takes little care of himself or his clothes. He is socially unskilled. He has little interest in anything other than his next meal. It is the image of the modern glutton that makes so many obese people defensive. Telling someone they eat too much implies all these things. That hurts.
Though obesity is the result of taking in too much energy and expending too little, few obese people actually fit the image of the stereotypic glutton. Roughly a third of Americans are obese. There are certainly many high functioning, tidy, charming people among them, who pay close attention to personal hygiene. Furthermore, many do not have a selfish obsession with food. After all, in no country in the world is food more abundant and less expensive than in America. Why obsess about getting something that can be had so easily? Indeed it is rare to see anyone, obese or not, gorging himself in public. Fear of being labeled a glutton may partly explain why. Many people are obese today because of an inappropriate and seemingly unconscious response to the presence of more food than one actually needs. Far from being ugly or gluttonous, this is easy to miss if one isn’t paying close attention.
One Monday morning a lady named Elaine called me in my office. She was in town for a few days and was a journalist interested in writing a story for a Chicago-based magazine on childhood obesity and wanted to interview me. I agreed to meet her for lunch the next day in the restaurant of the hotel where she was staying. I arrived on time but Elaine was already seated at a table in one corner. She was a very large woman who looked to be about fifty-five, but it wouldn’t have surprised me if she was younger. She wore a blue lady’s business pantsuit and looked sharp and professional.
“Thanks so much for taking the time to meet with me.”
“You’re very welcome.” I almost always honor requests for interviews. I believe I have a simple, straightforward message about childhood obesity and I take advantage of any opportunity to share it.
“I guess I didn’t expect you to be so slim,” Elaine said. I smiled and didn’t say anything. “I mean, in your book, you write with so much empathy for obese people, I would have thought it was something you struggled with. Were you overweight as a child?”
“No Elaine, I was not.” I was hoping this interview was not about me and actually about the epidemic of childhood obesity and what we as a society can do about it. We made small talk for a few minutes.
“As you can see, I struggle with my weight. It’s so hard to find anyone who understands. Most people are very judgmental, especially doctors.”
“That’s true. Some people, even doctors, don’t have the right attitude.”
“They don’t understand what overweight people have to deal with. You know, I was on the Atkins diet for a month. I lost about twenty pounds, but then I started gaining it back, so I stopped the diet. You’ve heard of that happening, right?” I began to fear that Elaine was more interested in getting help for herself than hearing about my perspectives of the problem among children.
“I don’t know, Elaine. I deal mostly with young children.”
“I know, I’m sorry. Didn’t mean to pick your brain about me. Well, if you had to give me your thoughts on how we can solve the problem of childhood obesity in a nutshell what would you tell me?”
I gave Elaine the same message I give everyone else: Today’s childhood obesity epidemic is the result of healthy children interacting with an unhealthy environment that encourages eating the wrong foods in large quantities and discourages physical activity. We will not solve the problem by building new playgrounds, starting new exercise programs, or getting children to try new diets. We have to look at the basic behaviors that have made children so obese in the first place and attack them one by one. These include high consumption of sweet beverages, high frequency of fast food consumption, and not walking to school, among others. Elaine offered, “I see, so you’re saying that if we get children to return to an earlier time, say how things were in the seventies, we could solve the problem?”
“That’s an interesting way of looking at it, Elaine. I think you’re right. In the seventies, most children walked to school, drank far less soda pop, fast food was only a special treat, and video games were practically non-existent. Children played outside after school.”
“Yes, but now aren’t children shuttling their children to soccer games and basketball practices?” This was a familiar point raised by many people that I always relish responding to.
“Exactly. Participation in organized soccer by children has exploded over the past thirty years, just like the epidemic of obesity. The ritual of taking a young child to a soccer game involves getting them dressed, driving to a location, providing lots of sweet drinks on the sidelines, and taking them to a fast food restaurant afterwards. I wonder how much of that total time is taken up by actual playing?”
“Interesting. Not much I would think.”
“Besides, I’ve always believed that in a typical child’s soccer game, 10% of the kids are playing 90% of the soccer.”
“Yeah, my daughter played soccer when she was younger. She wasn’t too ‘vigorous’ and was always heavy. She’s twenty-three now and still struggles with her weight just like me.” We continued to talk about the paradox between the availability of physical activity and diet programs and growing rates of obesity. Our waitress arrived a couple of minutes later.
“Hi. I’m Daphne. More bread for you two?”
“Yes, please” Elaine responded. I didn’t realize there had been any bread at all. Daphne returned promptly with a sliced warm loaf of artisan bread. It smelled wonderful.
“Your appetizer will be out shortly.”
“I hope you don’t mind, I ordered some nachos as an appetizer, but I haven’t ordered anything for lunch yet. Take your time and look over the menu.”
I took a quick glance at the menu and decided upon the eggplant parmigiana. I was hungry and I wasn’t picky at all. The nachos arrived a few minutes later and Daphne took our orders. Elaine ordered a pasta primavera.
“So, you’ve said diets and other ‘gimmicks’ don’t work. Tell me more about that.”
“Essentially Elaine, obesity is a complex problem. You cannot fix a complex problem with a very simple solution. It doesn’t make sense. Besides, and most importantly, people don’t get to be obese by not being on a diet or not taking some pill or using a strange piece of exercise equipment. They become obese by engaging in behaviors that make them obese – behaviors they’re sometimes not even aware of.”
“This is great stuff. It will make for a great article.” We each helped ourselves to a few nachos. Elaine drank some more of her ginger ale that she had ordered before I arrived. I had some water.
“So, how did you get so interested in childhood obesity anyway?”
I’ve always been passionate about preventing chronic disease. I told Elaine about how many adult problems such as heart disease, diabetes, and high blood pressure have their roots in childhood and that if we want to prevent such problems, we need to begin with the youngest members of our society. Daphne returned with our entrees.
“Can I take that plate away?” The plate of nachos was empty. I had had no more than a tenth of it.
“Sure, and could I trouble you for more ginger ale?” Elaine asked. Daphne returned with a full glass. Elaine put away her notebook and we suspended our conversation for a few minutes to enjoy our meals. My eggplant parmigiana was hot and delicious. Elaine’s pasta primavera looked great too. “This is really good. Would you like to try some?”
“No thanks Elaine. Would you like some of this? It is really quite good.”
“Hmm…Sure, maybe a little bit.” I cut off a piece of eggplant and placed it on her plate.”
“You’re right. Very nicely done. This place is great for a hotel restaurant.”
“Yes, it’s not bad at all. A lot of folks from the university and the hospitals eat here.”
Both our entrees came with a salad and more bread. The bread smelled wonderful once again. Elaine finished part of her pasta and paused to have a few slices of bread while it was still hot.
“This is terrific bread, isn’t it?”
“Definitely. Smells so fresh.”
We resumed the interview once again. We talked about how I approach a family with a child struggling with his or her weight. I finished my salad and most of my eggplant parmigiana.
“You’re not having your bread?”
“No, Elaine, I think I’m full. But, please, help yourself.”
“Thanks. I’ll just have a little bit.”
I slid the basket with four slices of bread toward her. She dipped one in the plate of olive oil that was on our table and ate it just before finishing her pasta. I got paged at that moment. It was a pharmacy calling about a refill of medications.
“Excuse me Elaine, I’m just going to step outside for a moment where it’s quieter.”
“Sure, please go ahead.” I returned a couple of minutes later just as Daphne had returned to our table.
“Are you all through?”
“Yes, I believe so,” Elaine responded. The remainder of the bread was gone. Daphne cleared away the table.
“Any dessert or coffee for you two?” We both ordered coffee.
“What types of desserts do you have?” Elaine asked. Daphne listed a couple of pies, some cakes and something else. I didn’t pay attention to the list.
“Would you care to share a Black Forest cake?”
“I’m not much of a dessert person Elaine, but please go ahead and order it.” Daphne smiled once again. I smiled back at her.
“OK, I’ll be right back with that.”
“She seems very nice. Very lucky girl,” Elaine commented.
“Why lucky, Elaine?”
“’She’s very attractive. I bet she gets all kinds of attention. You know, the kind of girl men open doors for all the time.”
I laughed. “I don’t see too many men opening doors for women these days.”
“True. You know what I mean, though. Beauty is power.”
“True Elaine, it is.”
“You’ve written a bit about that too – about how thin women get all the breaks and obese women are discriminated against.”
“I didn’t put it exactly that way, but there is no question that obese women are at a disadvantage.”
“I know the feeling exactly. I feel like I’m invisible sometimes, until people get to know me. You know, you walk into a store and the sales clerks barely notice you. You walk into a room for a meeting and it’s like you’re not there. It’s probably the exact opposite of what you experience. I mean, people probably gravitate toward you.”
“I don’t know about that, but I certainly don’t feel invisible.”
“I do. A lot of the women I work with at the magazine are thin and gorgeous. They get all the attention. You know, I was thin once too. Then I met my husband, and let me tell you, he likes his food. Then came a couple of kids. Now I’m invisible.” Elaine suddenly had a very serious look on her face. Her eyes welled up a bit, and a single tear streaked down her left cheek.
“I’m so sorry to hear that Elaine. I hear stories like that from some of the children I care for and their parents. It’s heartbreaking.” Daphne returned with one slice of Black Forest cake and two small forks. Elaine asked for a refill of her ginger ale.
“I bet it’s heartbreaking. Well, anyway, I’m sorry to burden you with my personal struggles.”
“Nah, don’t worry about it.” I had gotten my message out about childhood obesity. I was happy at that time to provide Elaine with my sympathy and support.
“Try some of this cake. It’s very moist.” I broke a small piece from the edge.
Elaine took out her notebook once again to make some final notes. She asked me to write down the names of other people that might be good to interview for her story about childhood obesity. Daphne returned while I did this.
“How was the cake?”
“Delicious,” Elaine responded. There was no cake left. “Could I have one last ginger ale?”
“Of course. Anything else?”
“No, just the check.” Elaine finished one last glass of ginger ale and we settled our bill.
“Well, thank you so much for your time. It was all very helpful.”
“You’re very welcome Elaine.”
“And thanks so much for suggesting the hotel restaurant. It was a pleasant surprise.”
“Yes, it’s really quite good.”
“Yes, and it’s so nice to eat light for a change.”
I smiled, shook her hand, and went back to work.
- Okholm D. (2000) Rx for Gluttony. Christianity Today, 44(10):6.2
GOUTHAM RAO, MD is Clinical Director of the Weight Management and Wellness Center at Children’s Hospital of Pittsburgh and Associate Professor of Pediatrics at the University of Pittsburgh School of Medicine. He is the author of many scientific publications including three books.