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Response to Review no. 838

Thank you for allowing us to respond to this review by Sander Gilman whose work we have admired and enjoyed.

The purpose of a review, however, is to give potential readers an idea of what to expect from a book. Gilman disappoints by using the flimsiest of references to Fat, Gluttony and Sloth as a hook to write an essay of his own on swine flu, HIV, BSE, tobacco, drugs and child abuse, finished off by what might be considered as a brazen plug for his own work. In fact the majority of his review is lazily cut and pasted from pp. 20–2 of his own Fat: a Cultural History of Obesity.

But more disappointing is his misunderstanding or misinterpretation of the aim and the audience of our book which we hope will be read and enjoyed by a general readership as well as to those particularly interested in medical, social and cultural history. With this in mind, we have deliberately avoided using such complex language as that sometimes employed by the reviewer in order to make our study accessible to a wider readership. In his review Gilman states: ‘The Haslams believe that their physiology of fat reflects transhistorical (evolutionary or physiological) truths, not cultural meanings grafted onto the social implications of body size’.

a) We are not sure what this sentence means (or why we seem been granted our own physiology)

b) This is an example of the rather complex language that we have omitted in Fat, Gluttony and Sloth in order to ensure that our study is widely accessible.

The global obesity epidemic is a recent phenomenon, and there has been a dearth of research or literature on its history. Gilman’s work is an admirable exception, and Fat, Gluttony and Sloth acknowledges its importance, especially ‘Fat boys’, which is referenced several times.
There are different strands of work relating to the history of obesity by various commentators: work such as Gilman’s written from the academic cultural historian’s viewpoint, and aimed at an academic and intellectual readership; versus that of authors such as George Bray from the Pennington in Baton Rouge and Stephan Rössner from Karolinska in Stockholm, both world leaders in the medical science of obesity and its clinical management. Fat, Gluttony and Sloth follows in the footsteps of its clinical predecessors, but is aimed at a wider, less academic, more general audience. Gilman’s own new volume advances the cause of cultural studies, but is not from the same pool as Fat, Gluttony and Sloth so should not be held up as a competitor. Fat, Gluttony and Sloth is the first time all the strands from clinical to pharmacology, art, literature and religion have been drawn together in one work, and has been done from the perspective in which its authors are skilled.

The distinction between a clinician’s view of obesity and a historian’s could not be better highlighted than by Fat: A Cultural History of Obesity, Gilman’s new offering. His historical and sociological views are excellent and entertaining. But when Gilman turns to clinical matters, the result is woeful confusion. His mixing up of narcolepsy (‘narcolepsy seems to be the appropriate diagnosis for the fat boy’s problem’ (p. 65)) and obstructive sleep apnoea, in a youth whose Epworth Score is off the scale, but has no evidence of narcolepsy is naive, but his confusion surrounding hypothyroidism and hyperthyroidism: Graves disease, myxoedema, and thyrotoxicosis; is unforgivable. His suggestion of treating ‘exophthalmosis’ (actually ‘exophthalmos’) with thyroid extract, would get him struck off the medical register in an instant. His application of ancient, historical, non-evidence-based, psychological regimes to assess Dickens’ ‘Joe’s’ mental state to a 21st-century readership is disingenuous to say the least. Whereas Gilman trawls literary critics’ views on Dickens’ work, we assess the clinical aspects of his condition based on the original text rather than speculation.

David Haslam is a practising GP who sees around 10,000 patients per year in primary care, as well as many of the biggest people in society in his twice weekly Luton and Dunstable Hospital Bariatric Surgery Clinic. He has recently been awarded an Honorary Chair at Robert Gordon University in Aberdeen in recognition of his international work in producing guidelines and providing education to combat obesity. He is chair of two national charities with the same aim, and has written several text books and over a hundred scholarly articles on the subject. Fiona Haslam’s career was spent in clinical medicine until her retirement when she obtained a degree in art history and a PhD for her work on medicine in art, and has written extensively on the subject. Hence the book has been written mainly from a clinical perspective, as the authors have a unique body of knowledge and experience in this arena.

With regard to our use of medical imagery, chapter 12 is prefaced by an acknowledgement that images are used by artists to express meaning in narrative, and that their views might be biased and do not necessarily reflect the true picture in society as a whole. They do, however, provide some useful information regarding the presence of obesity and perceptions of how it has been viewed over the years.  Gilman’s comment, therefore, that we have notions that our representations ‘validate medical views’ is unwarranted.

To address specific criticisms:

1) ‘These associations [gluttony and sloth] are seen as being very time-bound and rooted in specific cultural and/or religious views of the body’. The authors are documenting historical views and comparing and contrasting them to modern attitudes.

2) ‘Yet in the 21st century even the new global medicine of obesity stresses that there may well  however, are social and genetic-physiological explanations:’ The multifactorial nature of obesity – clinical, environmental and cultural – is clearly tackled in the book, from the introduction onwards

3) A shift in ‘quality of life’ and life expectancy. We live longer now, have less physically stressful occupations, and have easier access to more food. ‘The epidemic of obesity can be understood as a logical consequence of the fact that it has become progressively easier to consume more calories while expending fewer’ This statement is comprehensively covered from the introduction onwards. To die 10 years prematurely, a person must achieve ~65 years, and as the obesity epidemic is in its relative infancy, most obese individuals have not gained sufficient age to die ten years prematurely. When they do, we will see life expectancy reduce.

4) The 1950s onwards isn’t ignored, just (in the main) beyond the scope of the book. Modern diets and behavioural/psychological regimes are documented by other authors, and outside the sphere of relevance of this book, but Fat Gluttony and Sloth covers good and bad science equally.

5) Gilman’s ‘criticism’ of our ‘basic’ approach is perhaps a compliment. It is a popular, entertaining, sometimes provocative, approach to the subject of obesity, covering aspects of the history of obesity through medicine, literature and art.

Fat, Gluttony and Sloth is not intended to compete with volumes such as Gilman’s own excellent work, but to be complementary to it, intending to attract a different readership to the subject.