Atul Gawande and The Cheesecake Factory
Let Them Eat Cheesecake
By Suzanne Gordon
The other day, at the suggestion of Boston surgeon and New Yorker writer Atul Gawande, my husband and I made a lunchtime visit to The Cheesecake Factory. In his latest New Yorker article, “Big Med,’ Dr. Gawande touted the national chain restaurant as a model of the kind of standardization and quality that have been so lacking in healthcare. The Cheesecake Factory, he argues, delivers “delicious’ meals that represent just the kind of affordable, reliable product that would better fit the budgets of cost-conscious health care providers–and meet the needs of their “customers”–in the competitive new world of medicine. The chain’s highly profitable and efficient “model represents our best prospect for change” in health care, he argues.
This Rx from a well-respected and generally insightful physician who has become a leading health policy observer surprised me. Is this the same local physician/author who, in his book “The Checklist Manifesto: How To Get Things Right,” waxed poetic, about the creative, collaborative, non-hierarchical kitchen culture of Jody Adams, the renowned chef and owner of Rialto in Cambridge?
Inspired three years ago, by the “level of skill and craft” Adams and her staff displayed, he contrasted their “ever evolving, refined, and individual[ized]” menu with the “Taylorized, assembly line” methods of popular fast food chains. The key to quality chez Adams was information sharing and cooperation among co-workers, and the disciplined use of “communication checklists” to “ensure that people recognized and dealt with unexpected problems as a team.” How could the Cheesecake Factory have suddenly eclipsed Rialto in the area of institutional quality, innovation, and every-day excellence? What was more, how could a healthcare observer like Gawande, who has written about the need for greater attention to disease prevention, enhanced patient safety and curbing escalating healthcare costs, tout a chain like The Cheesecake Factory, which has earned a reputation as a proverbial production line of obesity.
Maybe something had changed at the chain and I should go to my nearest Cheesecake Factory to see if it had.
It hadn’t. On my subsequent visits to the chain restaurant in several locations I found enormous portions of food that was larded with fat, swimming in sugar and drowned in salt.
Of the 50 people in the restaurant when I went my husband for lunch several weeks agoat at least 15 were overweight. Four of the customers were morbidly obese. One woman was so huge, she had to use a walker. Her husband was also grossly overweight and her son, who was tucking into a monster plate of ravioli was well on his way to joining them in tipping the scales.
` My husband and I ordered from the small plates menu. My “small” kale salad was enough for four. The salad dressing was a combo of fat and sugar that was distinctly undelicious. At the table next to us, a young man was eating a Chinese salad. The plate it arrived on had to be 12 inches in diameter and the hillock of salad was at least 6 inches high. The waiter told us that this was just a luncheon portion — the dinner portion was twice as much and came on a plate the size of a tray. An overweight African American woman nearby was eating what looked like the meal Dr. Gawande had ordered – salmon with mashed potatoes. The salmon looked to me like over half a pound and there was at least a cup and a half of mashed potatoes (made with plenty of butter and cream, the waiter cheerfully explained). After downing all the salmon, she lost her valiant struggle to clean her plate and asked to take the potatoes home. Other folks were digging into similarly over the top portions –a burrito the size of a mini football field and a portion of meatloaf that was, again to use the waiter’s description, “gigantic.”
We finished the meal off with a piece of Reese’s peanut butter cup chocolate cheesecake, which we took home not to eat but to weigh. One slice for one person came in at six ounces and was accompanied by a third of a cup of highly sweetened whipped cream.
In our society we are coping with record levels of obesity as well as diabetes – even in young children. Obesity leads to all kinds of dreadful health problems – diabetes being only one, whose effects Dr. Gawande surely sees in his practice. Not only does obesity lead to terrible human suffering, it leads to sky rocketing healthcare costs. A 2008 article in Health Affairs estimated that the cost of caring for the obese with their complex chronic illnesses was $147 billion in that year alone. In 1998, dealing with the health consequences of obesity took up 6.5% of healthcare spending. By 2008, it had jumped to 9.1%.
In 2011, Science and the Public Interest gave the cheesecake factory one of its Extreme Eating awards for its Farmhouse Cheeseburger which has “1,530 calories and 36 grams of saturated fat topped with 3,210 milligrams of sodium. That’s assuming you just eat the burger: French fries bring an additional 460 calories and 1,460 mg of sodium. “ Of restaurants like The Cheesecake Factory, The Center’s nutrition director Bonnie Liebman says, “It’s as if the restaurants were targeting the remaining one out of three Americans who are still normal weight in order to boost their risk of obesity, diabetes, heart attacks, and cancer.”
In his book, The End of Overeating: Taking Control of the Insatiable American Appetite, physician and former head of the Food and Drug Administration David A. Kessler, singles out The Cheesecake Factory for its deliberate decision to overuse sugar, fat, and salt to encourage over-consumption. Like the tobacco industry manipulated its product to encourage addiction, restaurant chains like The Cheesecake Factory are, as Gawande argues, innovative. They use scientific innovation to make sure that their product encourages the kind of overeating that
In perhaps the understatement of the new century Dr. Gawande allows that the restaurant chain may serve portions that are a bit too big and fatty. But he says, The Cheesecake Factory “knows its customers.” So do doctors. Does this mean they should continue to give us anti-biotics we don’t need and order MRIs an CTs which , patients , in our ignorance, too often demand? Which is why touting a model like the to a chain like The Cheesecake Factory only throws fat – as well as salt and sugar – onto an out of control fire.