Belly fat or bloating? New insights into the physical appearance of St Anthony of Padua

Abstract

Over the centuries, iconographic representations of St Anthony of Padua, one of the most revered saints in the Catholic world, have been inspired by literary sources, which described the Saint as either naturally corpulent or with a swollen abdomen due to dropsy (i.e. fluid accumulation in the body cavities). Even recent attempts to reconstruct the face of the Saint have yielded discordant results regarding his outward appearance. To address questions about the real appearance of St Anthony, we applied body mass estimation equations to the osteometric measurements taken in 1981, during the public recognition of the Saint’s skeletal remains. Both the biomechanical and the morphometric approach were employed to solve some intrinsic limitations in the equations for body mass estimation from skeletal remains. The estimated body mass was used to assess the physique of the Saint with the body mass index. The outcomes of this investigation reveal interesting information about the body type of the Saint throughout his lifetime.

Full text

RESEARCH ARTICLE
Belly fat or bloating? New insights into the
physical appearance of St Anthony of Padua
Jessica MongilloID*, Giulia Vescovo ID, Barbara BramantiID
Department of Environmental and Prevention Sciences, University of Ferrara c.so Ercole I d’Este n.32,
Ferrara, Italy
*jessica.mongillo@unife.it
Abstract
Over the centuries, iconographic representations of St Anthony of Padua, one of the most
revered saints in the Catholic world, have been inspired by literary sources, which described
the Saint as either naturally corpulent or with a swollen abdomen due to dropsy (i.e. fluid
accumulation in the body cavities). Even recent attempts to reconstruct the face of the Saint
have yielded discordant results regarding his outward appearance. To address questions
about the real appearance of St Anthony, we applied body mass estimation equations to the
osteometric measurements taken in 1981, during the public recognition of the Saint’s skele-
tal remains. Both the biomechanical and the morphometric approach were employed to
solve some intrinsic limitations in the equations for body mass estimation from skeletal
remains. The estimated body mass was used to assess the physique of the Saint with the
body mass index. The outcomes of this investigation reveal interesting information about
the body type of the Saint throughout his lifetime.
Introduction
St Anthony of Padua (born Ferdinando Buglione, Lisbon 1195- Arcella, Padua 1231), is a saint
venerated by the Catholic Church. He is very popular in Italy as well as being the Patron Saint
of Brazil, Portugal and of the Custody of the Holy Land. The cult of St Anthony spread rapidly
in the Mediterranean Catholic world during his lifetime due to his reputation as a thaumaturge
and expanded globally in the 16
th
and 17
th
centuries thanks to the Portuguese cultural influ-
ence. In 1946, he was proclaimed a Doctor of the Universal Church [1]. Apart from the devo-
tional aspect, several famous painters and sculptors have tried to propose a historically
credible portrait of the Saint. The artists made different use of the information derived from
hagiographic sources. The representation of St Anthony by Giotto School (1238–1310) (Fig
1A) seems to be inspired by the opus Vita prima o Assidua (1232, by Anonymous, this work
represents one of the most important hagiographic sources), which described St Anthony in
the last months of his life as endowed with a “natural corpulence” (Vita Prima, XI,7, p. 159)
[2]. However, in the Legenda Raymondina, attributed to the Italian Franciscan Pietro Rai-
mondi and dated around 1293 [3] the term ‘dropsy’ was firstly reported referring to the condi-
tions of the Saint at the end of his life (“Cum enim esset naturali corpulentia gravis et hydropisi
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OPEN ACCESS
Citation: Mongillo J, Vescovo G, Bramanti B
(2021) Belly fat or bloating? New insights into the
physical appearance of St Anthony of Padua. PLoS
ONE 16(12): e0260505. https://doi.org/10.1371/
journal.pone.0260505
Editor: Efthymia Nikita, The Cyprus Institute,
CYPRUS
Received: July 14, 2021
Accepted: November 10, 2021
Published: December 21, 2021
Copyright: ©2021 Mongillo et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
information files.
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.

etiam laboret. . .” “Despite being severely corpulent by nature, and also afflicted with
dropsy. . .”) (Raymundina, IX, 5, p. 26) [4]. In the Assisi’s frescos, dated to the years 1292–
1296 (Fig 1B), Giotto portrayed St Anthony in a suffering condition, with a bloated belly,
which possibly recalls a “dropsy”.
In ancient times, the term ‘dropsy’ was commonly used to describe generalized abdominal
swelling (oedema or fluid retention), a symptom that is often associated with heart failure [5].
The written sources closest in time to the life of the Saint (Vita Prima written immediately
after the death of St Anthony and Legenda Raymondina, written around 60 years later) seem to
report both corpulence and dropsy as two distinct conditions. Both conditions have influenced
all the subsequent representations and descriptions of the Saint. Indeed, the hagiography pro-
posed by the Abbot Emanuelle De Azevedo (1832) described the Saint as short in stature, well-
nourished and puffy with a round face, lively eyes, a high forehead, a beautiful, affable, and
cheerful physiognomy, whereas dropsy is proposed as the cause of his bloated abdomen [6].
In 1981, in the context of the public ostension of the skeletal remains of the Saint, classical
anthropological analyses and osteometric measurements were carried out by Cleto Corrain to
answer some key questions about his life history. On this occasion, a cast of the skull was
made, which allowed the sculptor Roberto Cremesini to attempt a more scientific reconstruc-
tion of the face of St Anthony. The Saint was represented with an oblong face and hollow eyes
(Fig 1C), in agreement with the description of another literary source, the Sancti Antonii con-
fessoris de Padua vita of Sicco Ricci Polentone (c. 1435) [7]. This is the only text that proposes
a portrait of St Anthony with the same characteristics as in Cremesini’s work. In 2014, from
the same cast, a 3D cranio-facial reconstruction was proposed, using both anthropological
data and information from historical written sources [8]. To generate a more realistic face, the
Fig 1. The representation of St Anthony. (A) St Anthony giving his blessing, Giotto School. This portrait is
considered to reflect the true effigy of the Saint. Padova, Basilica del Santo (1238–1310), Giovanni Pinton/ Archivio
Fotografico Messaggero di Sant’Antonio, 2020. (B) Giotto, St Francis appears in the Chapter of Arles, ca. 1295–
1299. Assisi, Chiesa Superiore of Basilica di San Francesco. In the detail, St Anthony is illustrated suffering, with a
bloated abdomen. (C) Bust of St Anthony, detail. Bronze sculpture by Roberto Cremesini, 1995. This is a scientific
reconstruction of the ’real’ face of the Saint, based on the skull found after the recognition of his body in 1981. In
the reproduction of this bust, the artist relied on the advice of three scholars: C. Corrain (anthropologist), V.
Meneghelli (anatomist) and V. Terribile Wiel Marin (anatomopathologist). Photo by Giorgio Deganello/ Archivio
Fotografico Messaggero di Sant’Antonio, 1995. (D) The 3D Forensic Facial Reconstruction of St Anthony of Padua.
Cicero Moraes—Opera propria, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=33660858.
https://doi.org/10.1371/journal.pone.0260505.g001
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depth of the soft tissues was chosen from tables for an overweight body mass index (BMI>25)
[9], although no attempt was done before to directly calculate the BMI from the skeletal
remains [8] (Fig 1D).
Using osteometric measurements taken during the body recognition in 1981 [10], we
applied estimation formulae to calculate St Anthony’s actual body mass (BM), and to address
the question whether he was “naturally” overweight or not. Body mass estimation from skeletal
remains relied on two approaches: the morphometric and the mechanical approach [11]. The
morphometric method is based on the relationships between stature and selected body breadth
measures [12]. In particular, the combination of stature and bi-iliac breadth (ST/BIB) has been
frequently used on skeletal remains [13–19]. By contrast, the mechanical approach is built on
the dimensions of the skeletal elements that mechanically support the weight of the body [11].
Femoral head breadth (FHB) has been mostly used for this purpose [11,12,20–29]. Mechani-
cal methods are the most widely used, as they take in account several dimensions of different
articular surfaces such as that of the knee, but also diaphysis breadths, and cross-sections of
the bones [30–32]. Incidentally, these are the anatomical elements that are most preserved in
the archaeological record. In addition, several studies focus on the relationship between weight
and degenerative joint disease to improve understanding of the effect of the weight on joints
[33–38].
We calculated the Body Mass Index (BMI), developed by Quetelet in 1832, and known as
BMI since 1972 due to the work of Keys et al. (1972) [39,40], to categorize the weight condi-
tion of the Saint. The BMI classification employed by the World Health Organization (WHO)
and by the Center of Disease Control and Prevention (CDC) is useful to classify individuals
according to weight and height and assess the health risk associated with weight [41].
Despite the difference in activity and adiposity levels between past and present populations,
the BM formulas and the BMI can be employed in both bio-archaeological and forensic con-
texts as a valuable procedure to implement the biological profile of an individual.
Materials and methods
The osteometric measurements of the bi-iliac breadth, femoral head breadth, femoral bi-epi-
condylar breadth and breadth of the tibial plateau were taken from published data [10]. In
1981, Cleto Corrain carried out the osteometric recognition on occasion of the public osten-
sion of St Anthony’s skeletal remains.
We estimated the body mass of St Anthony according to several methods previously pub-
lished (Table 1):
Table 1. Regression equations of body mass estimation that were used in this study, and their SEE (standard error
of the equations, as reported in the quoted studies).
Authors Equations SEE
Ruff et al., 1991 BM = 2.741 �FHB-1 −5.9 13.7
McHenry, 1992 BM = 2.239 �FHB-2 −39.9 0.033
Grine, 1995 BM = 2.268 �FHB-3 −36.5 4.3
Ruff et al., 2012 BM = 2.80 �FHB-4 −66.7 6.8
Niskanen et al., 2017 (1) BM = 0.600 �FHB-5 + 0.206 �FXL −56.536 6.7
Niskanen et al., 2017 (2) BM = 0.467 �ST-2 + 3.761 �LBIB −119.537 8.93
Ruff et al., 2005 BM = 0.422 �ST-1 +3.126 �BIB −92.9 3.7
Keisu et al., 2019 (1) BM = 1.07 �FBEB −15.88 10.6
Keisu et al., 2019 (2) BM = 1.25 �TPML −22.75 10.7
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1. Femoral head body mass estimation (FHB-1), a sex-specific method [12]
2. Femoral head body mass estimation (FHB-2) [22]
3. Femoral head body mass estimation (FHB-3) [20]
4. Femoral head body mass estimation (FHB-4) [42]
5. Femoral head body mass estimation (FHB-5), combined with the femoral maximum length
(FXL) [18]
6. Knee measurements: femoral epicondylar breadth (FBEB) and medio-lateral breadth of the
tibial plateau (TPML) [43]
7. The stature/bi-iliac method 1 (ST/BIB-1) [14]
8. The stature/bi-iliac method 2 (ST/BIB-2) [18]
We estimated the stature from the skeleton according to Trotter & Gleser (1958) [44], using
the average of the maximum lengths of the left femur, tibia, fibula, humerus and the right
radius and ulna (measurements of the left radius and ulna were not recorded, since the bones
were exhibited as a relic elsewhere). The employment of these equations appears to be appro-
priate, as shown by the calculation of the crural index for St Anthony (81.2), which is very sim-
ilar to that obtained by Trotter & Gleser (1958) [44] for male individuals (81.9).
Following the advice of Elliott et al. (2016) [17] and the indications of Auerbach & Ruff
(2012) [11], we calculated the average of three FHB estimates (1;2;3). Averaging the three FHB
equations is the best approach when an individual does not fit one of the equations, which are
targeted at small body-size [22], large body-size [20], and modern populations [12],
respectively.
The measurement of the skeletal bi-iliac breadth was transformed in an assessment of the
living bi-iliac breadth following the formula of Ruff (1997) [45], Living = Skeletal x 1.17–3
(cm). In order to obtain information about the nutritional status of St Anthony, the body mass
index, BMI kg
m2
 �, was calculated as well, using the estimations of BM. Following the suggestions
of WHO and CDC, a BMI value below 18.5 indicates underweight conditions; BMIs between
18.5 and 24.9 indicates normal weight conditions; overweight conditions is considered if the
BMI is 25–29.9, and obese if it is a BMI greater than 30.
Results
The estimation of the stature, obtained with the method of Trotter & Gleser (1958) [44] reveals
a value of 171.1±3.23 cm, which is similar to the stature defined by Cleto Corrain averaging
the estimations obtained from all long bones (172.1 cm), independently of the laterality. How-
ever, Corrain attempted other assessments to conclude that St Anthony’s stature was likely 170
cm. Taking into account his conclusion and considering that this stature is included within the
range we have calculated, we decided to use this value for the calculation of the BMI.
Table 2 shows the BM estimation values (kg) and the BMIs obtained from the different
regression equations. In general, all formulae of the biomechanical method yielded lower val-
ues, with the FHB-4 formula [42] providing the smallest value (60.8±6.8). The average of the
three combined formulae (FHB-1-2-3) indicates low value of body mass as well (66.2±6.0).
The combination of stature and living bi-iliac breadth (morphometric method) yielded the
highest values both applying the formula of Ruff et al. (2005) [14] (75.5±3.7), and that of
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Niskanen et al. (2017) [18] (76.0±3.6). Similar values resulted from the equation based on the
knee joint dimensions of Keisu et al. (2019) [43] (76.1±10.6; 78.5±10.7).
BMI calculations based on the morphometric equations [14,18] and knee joint formulae
suggest a condition of overweight. The variation in estimated BM and BMI, depending on the
equations used, is illustrated in Fig 2.
Discussion and conclusions
We attempted to apply body mass estimation equations obtained from the literature to address
questions about the real appearance of St Anthony of Padua, one of the most revered Saint of
the Catholic Church. His portraits were strongly influenced by information evinced from liter-
ary sources, which from time to time referred to a natural or an acquired corpulence
(‘dropsy’).
Body mass estimation techniques are associated with a significant error, but several studies
have shown the reliability of these methods as powerful tools in the forensic and bio-archaeo-
logical field [33,46,47]. The error in estimation depends on several factors. Both morphometric
and mechanical approaches seem to perform better in case of normal weight or leaner individu-
als [17,48]. Moreover, it has been shown that the error is greater when body mass estimation
methods are applied to estimate individual BM, compared to the average BM of a population
[17,49,50]. In addition, several techniques were tested excluding obese individuals (in most
cases, people suffering from joint pathologies) [32,42]. However, possible bias can be solved
employing the biomechanical method in combination with the morphometric method [18,47].
Currently, obesity represents an ongoing pandemic, spreading worldwide with the diffusion of
“Western” diet and lifestyle [51,52]. Thus, the application of equations obtained from current
populations to archaeological remains may introduce a systemic error. The great majority of
individuals from the past were leaner and smaller than currently, due to differences in diet and
activity level [38,46,53,54]. Only small groups enjoyed food security in the past [55].
In other words, BM estimates from ancient skeletons should not be considered as exact
body masses, also taking in account that the weight of an individual slightly changes with a cir-
cadian rhythm. Nevertheless, BM estimation may contribute considerably to the assessment of
the individual body size from the skeleton [56].
The application of body mass estimation formulae to the skeletal remains of St Anthony
clearly showed two distinct conditions, from normal weight to overweight, as indicated by
the associated BMI (Table 2 and Fig 2). The lowest body mass values derived from the femo-
ral head equation [12,18,20,22,42] and the three combined equations account for a
Table 2. Body mass and body mass index of St Anthony of Padua.
Authors Application BM (kg) SEE BMI SD
Ruff et al., 1991 BM = 2.741 �45.5 −5.9 66.2 6.0 22.9 ±2.1
McHenry, 1992 BM = 2.239 �45.5 −39.9
Grine, 1995 BM = 2.268 �45.5 −36.5
Ruff et al., 2012 BM = 2.80 �45.5 −66.7 60.7 6.8 21.0 ±2.3
Niskanen et al., 2017 (1) BM = 0.600 �45.5 + 0.206 �471 −56.536 67.8 6.7 23.5 ±3.0
Niskanen et al., 2017(2) BM = 0.467 �171.1 + 3.761 �30.93 −119.537 76.2 8.93 26.3 ±1.3
Ruff et al., 2005 BM = 0.422 �171.1 +3.126 �30.93 −92.9 75.5 3.7 26.1 ±3.6
Keisu et al., 2019(1) BM = 1.07 �86 −15.88 76.1 10.6 26.3 ±3.7
Keisu et al., 2019 (2) BM = 1.25 �81 −22.75 78.5 10.7 27.1 ±2.1
SEE (standard error of equations, as reported in the quoted publications)
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weight’s range of 60.2±6.8 to 67.8±6.7kg. In contrast, formulae based on knee breadth and
bi-iliac breadth yielded values of 76.1±10.6 and 78.5±10.7kg [43], and 75.5±3.7 and 76.2±8.9
[14] (Fig 2).
An explanation for these apparently contrasting results might be found in the observation
that the femoral head size is more highly correlated with the body weight of an individual at
the age of 18 years [12], whereas bi-iliac breadth and development of the associated soft tissues
considerably increase in males up to the 40
th
year of age (0.8 mm/year) [57]. This finding
could suggest that the maximum weight of the Saint, reached before his death at the age of 38
years, was between 75.5±3.7 and 76.2±8.93, and his BMI 26.1±3.6 and 26.3±1.3. A strong cor-
relation between the actual body mass and the body mass estimated from stature and bi-iliac
breadth has been previously demonstrated, suggesting that this method is more accurate than
others to estimate the actual weight at death especially for young individuals and young adults
[18,58].
The response of articular joint size to weight is controversial. Several studies suggest that
joint size and shape do not change in response to variations in body mass [30–32]. However,
in the study of Keisu et al. (2019) [43], the correlation between knee breadth and body mass
Fig 2. Body mass and body mass index of St Anthony yielded with different regression equations. In the grey box the peak of BM and BMI
calculated using knee joint size and ST/BIB equations.
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at the age of 31 years was high, especially in males, who reach their peak height and physical
maturity later than females [59]. According to previous research, the body mass estimated
by knee joint size reflects the BM between 18 and 31 years [60]. All things considered, St
Anthony might have had a weight between 60.7 ±6.8 and 67.8 ±6.7 kg (BMI between
21.0 ±2.3 and 23.5 ±3.0) at the age of maturity, should have reached a weight between
76.1 ±10.6 kg and 78.5±10.7 (BMI 26.3 ±3.7 and 27.1 ±2.1) at 18–31 years of age, and a
weight between 75.5±3.7 and 76.2±8.93 kg (BMI between 26.1±3.6 and 26.3±1.3) at the time
of death (38 years).
Following the indications of CDC and WHO, the BMI of St Anthony seems to be in the
range of normal weight (BMI 18.5–24.9) at maturity, and in overweight condition (BMI 25 to
29.9) later in life. Currently, BMI classification is widely used in population-based studies to
assess mortality risk and can be used as a proxy to assess health conditions in past populations
[61]. However, estimating an individual BMI from the skeleton is difficult since it depends on
how accurate the estimation of BM and stature is [14]. In addition, large secular increases in
rates of growth (weight and stature) have occurred from last century, and the current BMI cat-
egories may not be appropriate for individuals of the past [41,62]. Nevertheless, our estima-
tions seem to be in agreement with the historical and hagiographic information.
Certainly, the weight of St Anthony fluctuated during his life. St Anthony’s life was very
active, he went preaching in many parts of Italy, including the hermitage of Montepaolo, and
he was in France to fund a hermitage and to preach [63]. He lived with other friars, devoted to
praying. Indeed, X-ray examinations showed an enlarged left tibia with marginal osteophyte
on the intra-epithelial eminence that demonstrates intense physical activity and long periods
spent on his knees [10]. Further, the tibia showed eburnated thickening of the diaphyseal cor-
tex, disappearance of the bony structure and partially obliterated medullary canal [10]. The
anthropologists who directly analysed the skeleton of the Saint referred these additional patho-
logical features to non-suppurative osteomyelitis, or sclerosing non-suppurative osteitis, or
localised sclerosis of the long bone, or chronic osteomyelitis, which had healed by the time of
his death. Written sources report that the Saint was struck in 1220, at the age of 25, by an
unspecified “fever” that arose during a period spent in Morocco [2,4,6]. After this feverish
episode, the Saint’s conditions are described as critical with physical weakness and difficulty in
standing [6]. These symptoms might be tentatively linked with the onset of osteomyelitis
which had in any case resolved by the time of his death.
In certain periods of his life, we know that he retired to a hermitical life [10], and used to
fast from time to time, or only eat bread and water (Vita prima o Assidua, XIII, 1-5pp. 160–
162). Indeed, his poor eating condition might be confirmed by pathological evidence of cribra
orbitalia on the skull [10], considered manifestations of anaemic conditions (e.g., [64]). The
occurrence of cribra orbitalia (grade 3, after Hengen 1971 [65], without no evidence of heal-
ing) was assessed by the palaeopathologists Gino Fornaciari, Francesco Mallegni, and Giorgio
Raglini. This condition may be due to a diet lacking fundamental elements and malnutrition.
The absence of maxillary and mid-facial bones hypertrophy, porosity of long bones, spine
deformity, malocclusion, typical signs of thalassemia or sickle-cell anaemia, makes the diagno-
sis of sideropenic anaemia more likely than a form of Mediterranean anaemia [10,66].
According to ancient sources, his dropsy was linked to the hermitic life, due to dietary dis-
orders and nutritional insufficiencies [67], while the palaeopathologists who examined the
skeletal remains of St Anthony have proposed an unspecified causal relationship of dropsy
with the afore mentioned feverish episode at young age [10].
In modern medicine, dropsy could account for a broad spectrum of diseases identified by
oedema and ascites, due to accumulation of serous fluids in body cavities [68,69]. One of the
most severe form of dropsy is ascites, a pathological accumulation of fluid in the peritoneal
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cavity, which might be related to congestive heart failure, an illness, which has been often pro-
posed as the actual cause of the death of the Saint [68,70–72].
The Raymundina also reports about St Anthony’s continuous need for water when he
retired to Montepaolo, at the age of 27. Increased thirst in people with heart failure has also
been described in connection with dropsy as ’thirsty dropsy’ by past and present physicians
[69]. Both Raymundina and De Azevedo’s biography mention dropsy only toward the end of
his life, and they also refer to an episode of suffocation in sleep that occurred during the Holy
Week 1231 and was attributed to the devil’s intervention [4,6]. In fact, it may have been an
attack of dyspnoea, a symptom that could be related to heart failure as well [72]. Patients with
a diagnosis of heart failure may notice an unexpected weight gain of >2 kg in 3 days, due to
fluid retention [73,74], but this weight gain is too rapid to be recorded in the skeleton. Possi-
bly, for St Anthony the pathological condition had become chronic and worsened in the last
months of his life, since the skeletal analysis of the Saint revealed the presence of an eversion of
the last ribs. The index of internal rib curvature suggests a decrease of curvature from the
eighth to the tenth rib, probably due to the progressive increase of the intra-abdominal content
[10,75].
In conclusion, in this study we aimed to reconstruct St Anthony’s body mass, define his
nutritional status, and find a solution for the riddle of his build, as proposed by the discordant
portraits of the Saint. From our analysis of the osteometric measures taken during the osten-
sion of his skeleton, we have proposed that Saint Anthony’s weight was normal at the end of
the growing process, while it was higher during the adult age when the Saint reached a condi-
tion of overweight. At an uncertain moment in his life, the Saint developed a dropsy–likely
due to chronic and progressive heart failure, which contributed to the development of his
bloated abdomen. This condition could have worsened with time, becoming a severe form of
ascites in the last months of his life.
Iconographic and literary sources emphasised the body size of the Saint as “corpulent”
because he was probably overweight, an unusual trait for a preacher of that time. However, the
sources likely described the Saint as corpulent because he was also swollen from dropsy. His-
torical records through ’devotional’ sources have possibly focused on his dropsy to demon-
strate the efforts and strength of his spirit, despite his ailing body.
Supporting information
S1 File.
(DOCX)
Acknowledgments
We are grateful to the Photo Library of the CSA (Centro Studi Antoniniani) and thank the
Photographic Archive of the Sacro Convento of San Francesco in Assisi for providing the pho-
tographic materials.
Author Contributions
Investigation: Giulia Vescovo.
Methodology: Jessica Mongillo.
Supervision: Barbara Bramanti.
Writing – original draft: Jessica Mongillo, Giulia Vescovo, Barbara Bramanti.
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