Liars and Fools
When we see obese patients there are generally two of us present in order to speed up routine handling. Thus when we have to investigate a rise in weight, a glance is sufficient to make sure that we agree or disagree. If after a few questions we both feel reasonably sure that the patient is deliberately lying, we tell him that this is our opinion and warn him that unless he comes clean we may refuse further treatment. The way he reacts to this furnishes additional proof whether we are on the right track or not we now very rarely make a mistake.
If the patient breaks down and confesses, we melt and are all forgiveness and treatment proceeds. Yet if such performances have to be repeated more than two or three times, we refuse further treatment. This happens in less than 1% of our cases. If the patient is stubborn and will not admit what he has been up to, we usually give him one more chance and continue treatment even though we have been unable to find the reason for his gain. In many such cases there is no repetition, and frequently the patient does then confess a few days later after he has thought things over.
The patient who is fooling himself is the one who has committed some trifling, offense against the rules but who has been able to convince himself that this is of no importance and cannot possibly account for the gain in weight. Women seem particularly prone to getting themselves entangled in such delusions. On the other hand, it does frequently happen that a patient will in the midst of a conversation unthinkingly spear an olive or forget that he has already eaten his breadstick.
A mother preparing food for the family may out of sheer habit forget that she must not taste the sauce to see whether it needs more salt. Sometimes a rich maiden aunt cannot be offended by refusing a cup of tea into which she has put two teaspoons of sugar, thoughtfully remembering the patient's taste from previous occasions. Such incidents are legion and are usually confessed without hesitation, but some patients seem genuinely able to forget these lapses and remember them with a visible shock only after insistent questioning.
In these cases we go carefully over the day. Sometimes the patient has been invited to a meal or gone to a restaurant, naively believing that the food has actually been prepared exactly according to instructions. They will say: “Yes, now that I come to think of it the steak did seem a bit bigger than the one I have at home, and it did taste better; maybe there was a little fat on it, though I specially told them to cut it all away”. Sometimes the breadsticks were broken and a few fragments eaten, and “Maybe they were a little more than one”. It is not uncommon for patients to place too much reliance on their memory of the diet-sheet and start eating carrots, beans or peas and then to seem genuinely surprised when their attention is called to the fact that these are forbidden, as they have not been listed.