The Gravity of Weight A CLINICAL GUIDE TO Weight Loss and Maintenance pdf

e Gravity of Weight
A CLINICAL GUIDE TO
Weight Loss and Maintenance
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Washington, DC
London, England
e Gravity of Weight
A CLINICAL GUIDE TO
Weight Loss and Maintenance
Sylvia R. Karasu, M.D.
Clinical Associate Professor, Department of Psychiatry,
Weill Cornell Medical College; Associate Attending Psychiatrist,
New York–Presbyterian/Weill Cornell Medical Center, New York, New York
T. Byram Karasu, M.D.
Silverman Professor of Psychiatry and University Chairman, Department of
Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine,
and Psychiatrist-in-Chief, Montefiore Medical Center, Bronx, New York
Note: e authors have worked to ensure all information in this book is accurate at the time of publica-
tion and consistent with general psychiatric and medical standards, and that information concerning
drug dosages, schedules, and routes of administration is accurate at the time of publication and consis-
tent with standards set by the U.S. Food and Drug Administration and the general medical community.
As medical research and practice continue to advance, however, therapeutic standards may change.
Moreover, specific situations may require a specific therapeutic response not included in this book. For
these reasons and because human and mechanical errors sometimes occur, we recommend that readers
follow the advice of physicians directly involved in their care or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the in-
dividual authors and do not necessarily represent the policies and opinions of APPI or the American
Psychiatric Association.
Disclosure of interests: e authors have no competing interests or conflicts to declare.
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Acknowledgment: Excerpts from e Art of the Commonplace: e Agrarian Essays of Wendell Berry,
©2003, and “e Gift of Gravity,” in e Collected Poems of Wendell Berry, ©1987, are reprinted by per-
mission of Counterpoint.
Library of Congress Cataloging-in-Publication Data
Karasu, Sylvia R.
e gravity of weight : a clinical guide to weight loss and maintenance / Sylvia R. Karasu, T. Byram
Karasu. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-360-0 (alk. paper)
1. Weight loss. 2. Weight loss—Psychological aspects. I. Karasu, Toksoz B. II. Title. III. Title: Clinical
guide to weight loss and maintenance.
[DNLM: 1. Obesity—psychology. 2. Obesity—therapy. 3. Body Weight—physiology. 4. Weight
Loss—physiology. WD 210 K18g 2010]

RM222.2.K37 2010
613.2’5—dc22

2009045790
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Cert no. XXX-XXX-XXXX
All scientific work is incomplete—whether it be observational or experimental.
All scientific work is liable to be upset or modified by advancing knowledge. at
does not confer upon us a freedom to ignore the knowledge we already have, or to
postpone the action that it appears to demand at a given time.
Sir Austin Bradford Hill (1965)
What has been one scientist’s “noise” is another scientist’s “signal.”
Martin Moore-Ede (1986)
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In memory of Cemil Karasu and Moses Rabson, M.D.
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CONTENTS
FOREWORD xvii
Albert J. Stunkard, M.D.
A TALE OF TWO FATHERS xxiii
Sylvia R. Karasu, M.D.
ACKNOWLEDGMENTS xxv
1 INTRODUCTION 1
The Unbearable Heaviness of Being . . . . . . . . . . . 1
The “Minded Brain” . . . . . . . . . . . . . . . . . . . . 5
The Dieter as Well as the Diet . . . . . . . . . . . . . . 7
2 OBESITY IN THE UNITED STATES:
T
HE GRAVITY OF THE SITUATION 11
Definitions of Obesity: Body Mass Index . . . . . . . . .11
Some Methodological Problems in Studying Obesity . .18
Genetics and Obesity . . . . . . . . . . . . . . . . . . .20

The National Weight Control Registry: Weight Loss
Versus Maintenance . . . . . . . . . . . . . . . . . .23
The Medical Consequences of Obesity . . . . . . . . .30
The Metabolic Syndrome . . . . . . . . . . . . . . . . . 35
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Other Medical Consequences of Obesity . . . . . . . . 38
Weight Cycling (Yo-Yo Dieting) . . . . . . . . . . . . . . 39
Discrimination Against the Obese . . . . . . . . . . . .44
3 FOOD: THE BASIC PRINCIPLES OF CALORIES. . . . . . 55
Factors Involved in Daily Energy Requirements . . . . .55
Carbohydrates . . . . . . . . . . . . . . . . . . . . . . .63
Classification of Carbohydrates . . . . . . . . . . . . . 64
Glycemic Index . . . . . . . . . . . . . . . . . . . . . . 65
High-Fructose Corn Syrup (HFCS) . . . . . . . . . . . 69
Nonnutritive Sweeteners . . . . . . . . . . . . . . . . . 74
Fiber . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Water . . . . . . . . . . . . . . . . . . . . . . . . . . .81
Energy Density . . . . . . . . . . . . . . . . . . . . . .84
Proteins . . . . . . . . . . . . . . . . . . . . . . . . . .86
Fats . . . . . . . . . . . . . . . . . . . . . . . . . . . .89
Fatty Acids . . . . . . . . . . . . . . . . . . . . . . . . 90
Fat Substitutes . . . . . . . . . . . . . . . . . . . . . . 92
Lipoproteins and Cholesterol . . . . . . . . . . . . . . . 92
4 THE PSYCHOLOGY OF THE EATER 101
Obesity as a Brain Disorder . . . . . . . . . . . . . . 101
Homeostasis, Allostasis, Stress,
and the HPA Axis . . . . . . . . . . . . . . . . . . . 106
Personality, Temperament, and Character . . . . . . . 113
Psychological Defense Mechanisms . . . . . . . . . . 117
The Psychology of Temptation and Self-Control . . . . 121

Reward, Cravings, and Addiction (Dopamine,
Endocannabinoids) . . . . . . . . . . . . . . . . . . 128
5 THE METABOLIC COMPLEXITIES
OF WEIGHT CONTROL 141
General Considerations . . . . . . . . . . . . . . . . . 141
The Set Point . . . . . . . . . . . . . . . . . . . . . . 143
Adipose Tissue . . . . . . . . . . . . . . . . . . . . . 146
Brown Adipose Tissue . . . . . . . . . . . . . . . . . .146
White Adipose Tissue . . . . . . . . . . . . . . . . . .147
Satiety . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Hormones of Food Intake . . . . . . . . . . . . . . . . 153
Gastrin . . . . . . . . . . . . . . . . . . . . . . . . . .153
Leptin . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Adiponectin . . . . . . . . . . . . . . . . . . . . . . . 159
Ghrelin . . . . . . . . . . . . . . . . . . . . . . . . . .161
Insulin, Amylin, and Glucagon . . . . . . . . . . . . . 164
Cholecystokinin . . . . . . . . . . . . . . . . . . . . 169
Neuropeptide Y . . . . . . . . . . . . . . . . . . . . . .170
Other Neurochemical Mechanisms Involved in Eating . .171
Conclusion . . . . . . . . . . . . . . . . . . . . . . . 174
6 PSYCHIATRIC DISORDERS AND WEIGHT 181
Cause or Consequence? . . . . . . . . . . . . . . . . 181
Excessive Weight and Comorbid Psychiatric
Symptoms . . . . . . . . . . . . . . . . . . . . . . 183
Dieting and Psychological Symptoms . . . . . . . . . 194
The Psychology of Weight Cycling . . . . . . . . . . . 197
Body Image, Fat Acceptance, and Body
Dysmorphic Disorder . . . . . . . . . . . . . . . . . 198
Certain Psychiatric Illnesses and Comorbid
Abnormal Weight . . . . . . . . . . . . . . . . . . . 201

Depression . . . . . . . . . . . . . . . . . . . . . . . .201
Hypochondriasis . . . . . . . . . . . . . . . . . . . . 205
Comorbidity of Eating Disorders
With Psychiatric Symptoms . . . . . . . . . . . . . 209
Binge Eating Disorder . . . . . . . . . . . . . . . . . .211
Anorexia Nervosa . . . . . . . . . . . . . . . . . . . . .213
Bulimia Nervosa . . . . . . . . . . . . . . . . . . . . .217
Comorbidity of Eating Disorders With Alcohol
and Drug Abuse . . . . . . . . . . . . . . . . . . . .219
Alcohol and Weight . . . . . . . . . . . . . . . . . . . 221
7 MEDICAL CONDITIONS AND WEIGHT 229
Some Physical Causes of Weight Gain . . . . . . . . 229
Sexual and Reproductive Functioning and Obesity . . 230
Pregnancy . . . . . . . . . . . . . . . . . . . . . . . .232
Smoking and Weight . . . . . . . . . . . . . . . . . . 237
Infectious Agents and Weight Gain . . . . . . . . . . 239
Medications That Cause Weight Gain . . . . . . . . . 241
Antipsychotics . . . . . . . . . . . . . . . . . . . . . .243
Mood Stabilizers . . . . . . . . . . . . . . . . . . . . .245
Antidepressants . . . . . . . . . . . . . . . . . . . . .246
Other Medications . . . . . . . . . . . . . . . . . . . .247
Cellulite (Gynoid Lipodystrophy) . . . . . . . . . . . . 248
8 EXERCISE 255
Exercise and Nonexercise Activity Thermogenesis . . 255
Exercise . . . . . . . . . . . . . . . . . . . . . . . . 256
Nonexercise Physical Activity . . . . . . . . . . . . . 259
Determinants of Exercise . . . . . . . . . . . . . . . . 262
Metabolic Consequences of Exercise . . . . . . . . . 263
Exercise for Initial Weight Loss Versus
Minimizing Weight Regain . . . . . . . . . . . . . . 266

Exercise and Appetite . . . . . . . . . . . . . . . . . . 271
General Health Effects of Exercise . . . . . . . . . . . 273
Exercise, Depression, and Anxiety . . . . . . . . . . . .273
Exercise and Cognitive Functioning . . . . . . . . . . .276
Exercise and Medical Consequences . . . . . . . . . .277
Recommendations: How Much, How Often,
What Kind? . . . . . . . . . . . . . . . . . . . . . . 285
9 CIRCADIAN RHYTHMS, SLEEP, AND WEIGHT 297
Biological Clocks . . . . . . . . . . . . . . . . . . . . 297
What Are Circadian Rhythms? . . . . . . . . . . . . . .297
The Master Clock: The Suprachiasmatic Nucleus . . . 299
Other Clocks (Central and Peripheral) . . . . . . . . . .300
Zeitgebers . . . . . . . . . . . . . . . . . . . . . . . .302
Chronotypes . . . . . . . . . . . . . . . . . . . . . . .303
Jet Lag . . . . . . . . . . . . . . . . . . . . . . . . . 304
Chronopharmacology . . . . . . . . . . . . . . . . . . .307
Hormones, Sleep, and Weight . . . . . . . . . . . . . 308
Orexins . . . . . . . . . . . . . . . . . . . . . . . . . 308
Ghrelin . . . . . . . . . . . . . . . . . . . . . . . . . .310
Serotonin . . . . . . . . . . . . . . . . . . . . . . . . .310
Histamine . . . . . . . . . . . . . . . . . . . . . . . . .311
Hibernating Animals and a Model for Human Obesity . .312
Sleep Disruption and Weight . . . . . . . . . . . . . . 313
Normal Sleep Architecture . . . . . . . . . . . . . . . .313
Fragmented Sleep, Excessive Daytime Sleepiness,
and Obstructive Sleep Apnea . . . . . . . . . . . . .314
Inadequate Sleep and Hormone Secretion . . . . . . . .317
High-Fat Feeding and Disrupted Rhythms . . . . . . . .319
Can Inadequate Sleep Lead to Obesity? . . . . . . . . .320
The Night Eating Syndrome

(Disorder of Circadian Rhythms) . . . . . . . . . . . 323
10 DIET AND WEIGHT 335
General Principles of Diet . . . . . . . . . . . . . . . . 335
Dieting Within Our Environment . . . . . . . . . . . . .335
The Science of Calorie Counting . . . . . . . . . . . .339
The Regimen of Diet . . . . . . . . . . . . . . . . . . .341
Early Research . . . . . . . . . . . . . . . . . . . . . 343
Clara Davis . . . . . . . . . . . . . . . . . . . . . . . .343
Ancel Keys . . . . . . . . . . . . . . . . . . . . . . . 345
Therapeutic Calorie Restriction . . . . . . . . . . . . . 347
Fasting for Weight Control . . . . . . . . . . . . . . . .347
Very-Low-Calorie Diets . . . . . . . . . . . . . . . . . 349
Calorie Restriction and Longevity . . . . . . . . . . . .351
Alternate-Day Fasting . . . . . . . . . . . . . . . . . . .353
Meal Frequency and Rate of Eating . . . . . . . . . . 354
Popular Diets . . . . . . . . . . . . . . . . . . . . . . 357
General Principles . . . . . . . . . . . . . . . . . . . .357
Examples of Dietary Supplementation . . . . . . . . . 358
The Advantages and Perils of High-Protein Diets
and Their Relationship to Low Carbohydrate and
High Fat Intake . . . . . . . . . . . . . . . . . . . 360
The Advantages and Perils of High-Carbohydrate
Diets and Their Relationship to Fat Intake . . . . . . 364
A Review of Some Popular Diets . . . . . . . . . . . .367
Recommendations for a Healthy Diet . . . . . . . . . . 373
11 PSYCHOLOGICAL TREATMENT STRATEGIES
AND WEIGHT 383
Our Psychological Relationship to Weight
and Food . . . . . . . . . . . . . . . . . . . . . . . 383
Psychological Treatment Modalities for Weight . . . . 386

The Psychodynamic Therapies . . . . . . . . . . . . .387
Interpersonal Therapy. . . . . . . . . . . . . . . . . . 394
Neurolinguistic Programming . . . . . . . . . . . . . . 395
Gestalt Therapy . . . . . . . . . . . . . . . . . . . . . 395
Cognitive-Behavioral Therapy . . . . . . . . . . . . . .397
Dialectical Behavioral Therapy . . . . . . . . . . . . . 399
Eastern Approaches . . . . . . . . . . . . . . . . . . .401
Self-Help . . . . . . . . . . . . . . . . . . . . . . . . .401
Research on Psychological Treatments for Obesity . . 407
Methodological Issues . . . . . . . . . . . . . . . . . .407
Research Data on Psychotherapeutic
Treatment Strategies . . . . . . . . . . . . . . . . . 408
Research Data on Self-Help Treatment Strategies . . . .412
12 PHARMACOLOGICAL AND SURGICAL TREATMENTS
FOR OVERWEIGHT AND OBESITY 421
General Considerations . . . . . . . . . . . . . . . . . 421
A Treatment Decision Tree . . . . . . . . . . . . . . . 427
Pharmacological Approaches to Weight Loss . . . . . 428
FDA-Approved Medications for Weight Loss . . . . . . .429
Off-Label Uses of Medications to Achieve
Weight Loss . . . . . . . . . . . . . . . . . . . . . .431
Dietary Supplements . . . . . . . . . . . . . . . . . . .436
Summary: Medication Management . . . . . . . . . . .437
Surgical Approaches . . . . . . . . . . . . . . . . . . 438
Plastic Surgery . . . . . . . . . . . . . . . . . . . . . .438
Bariatric Surgery . . . . . . . . . . . . . . . . . . . . 445
APPENDIX: SELECTED READINGS AND
W
EB SITES 461
I

NDEX 465
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xvii
FOREWORD
This book is a labor of love. As the authors state, it is “a tale of two fathers.” e
father of Sylvia Karasu suffered from morbid obesity all of his life, together with
other risk factors for coronary heart disease, and lived to the age of 91. e father
of Byram Karasu, also morbidly obese, died at the age of 56. is tale of two fathers
is in the background of the volume as the authors seek to assess the many factors
that contribute to obesity and its control.
e Gravity of Weight is a model of scholarly inquiry that describes and ana-
lyzes, in a critical manner, an enormous amount of information. With the possible
exception of a few references that may have been cited twice, I estimate that the
bibliography contains no fewer than 900 publications on every aspect of obesity,
covering the field to an extraordinary extent. e book is well written and thor-
oughly up to date, with few references earlier than the year 2000.
e authors’ goal in this volume is to integrate “the complex psychological and
physiological aspects of the mind, brain, and body” and to explain why the control
of body weight and its maintenance are “so daunting for so many people.” e prob-
lems that they raise and the analyses that they conduct go far to realize this goal.
Early in the book, I was struck by the discussion of two problems in the un-
derstanding of obesity. e first problem is the alteration of the largely linear cor-
relation between increasing body fat and mortality. It is the curious increase in
mortality that occurs in underweight persons. e authors carefully analyze the
data to show that the increase in mortality at the lower extent of fatness is not a
function of this decreased fatness. Instead, it is due to independent risk factors.
e second question deals with the issue of “weight cycling,” the widely held
belief that cycles of weight loss and regain are a cause of morbidity and mortality.
e authors deal with this belief by means of a thorough study of arguments for and
against it. eir final answer, one with which I agree, is that the question requires

xviii THE GRAVITY OF WEIGHT
such precision of measurement that it cannot be decided by currently available
data in humans.
e section on physical activity benefits from the care with which accurate,
quantitative measurements can be made. One such measure is the MET, or “meta-
bolic equivalent.” It is defined as the ratio of the activity performed compared to
sitting quietly (which receives a standard MET of 1). Values in METs are available
for essentially all activities and range from sleeping, at 0.9 MET, to running, at 18.0
METs.
Two articles in the New England Journal of Medicine point to the accuracy with
which measurements of physical activity can be made (Florman 2000; Levine et
al. 1999). e articles report that chewing gum for 12 minutes increased caloric
expenditure by 11 ± 3 kcal/hour, a value similar to that of standing, as opposed to
sitting. e experimenters make a playful estimate: if a person chewed gum during
waking hours and changed no other component of energy balance, a yearly weight
loss of 5 kilograms (11 pounds) should be expected.
e Gravity of Weight notes the three major components of energy expenditure:
the basal metabolic rate, which accounts for about 60% of average daily caloric
expenditure; the thermic effect of food (including its digestion, absorption, and
storage), which accounts for about 10%–15% of daily expenditure; and physical ac-
tivity. Physical activity is the most variable component, accounting for 15% (among
sedentary people) to 50% (among active ones). Physical activity is thus the major
factor on the energy output side of the energy balance equation, and it is important
to consider. Less than 50% of the American population exercises on a regular basis,
clearly a factor in the development of obesity but also an opportunity for favorable
change. Even relatively small amounts of exercise have an effect, but it is excep-
tionally difficult to lose weight by exercise alone. To lose weight, exercise must be
combined with caloric restriction and dieting, as discussed below.
Although exercise alone is of indifferent value in weight loss, it helps in the
maintenance of weight loss. A great many treatment studies have made clear the

strong tendency for weight loss programs to be followed by regain of the lost weight.
e amount of exercise to prevent regain in the average person is, however, formi-
dable: 45 to 60 minutes a day of walking.
In e Gravity of Weight, the section on circadian rhythms deals with a funda-
mental biological characteristic that is critical in weight control. We know about
these rhythms primarily when they are disrupted, as in jet lag and shift work. e
major biological clock, in the hypothalamus, is entrained to the 24-hour light/dark
cycle. It is supplemented by additional clocks in the body and by a number of “clock
genes.” ese additional mechanisms permit a finer degree of specialization among
the activities of the various organs.
Prominent among disruptions of circadian rhythms is the night eating syn-
drome, characterized by a delay of 1½ hours in the circadian pattern of food intake.
Night eaters consume at least 25% of their daily caloric intake after the evening
Foreword xix
meal and awaken during the night, with food intake, at least two to three times a
week. Control subjects, on the other hand, awaken less frequently during the night
and do not eat upon awakening. Night eating syndrome occurs in combination
with binge eating disorder in some people, and when this occurs, it is associated
with greater degrees of obesity. Night eating syndrome is present among nonobese
persons, and its prevalence rises with increasing levels of obesity, leading to the
observation that it is a pathway to obesity. e syndrome is readily diagnosed and
effectively treated. Patients benefit from relief of their distressing behaviors and
better control of their body weight. Unfortunately, the disorder usually goes un-
recognized and untreated.
e authors devote a section to intensive forms of psychotherapy and present
excellent short accounts of nine programs: Freud’s original drive theory, ego psy-
chology, object relations theory, self psychology, interpersonal relationship theory,
neurolinguistic programming, gestalt therapy, cognitive-behavioral therapy, and
dialectical behavioral therapy. Although the authors relate each of the therapies to
its potential use in the treatment of obesity, outcome research is confined to one

psychoanalytic study that included obese persons. erapy was administered by
practitioners of various schools of psychoanalysis, and the goals of treatment var-
ied widely. e goals did not include weight reduction, but nevertheless significant
weight losses were achieved. Clearly, the cost of weight reduction by these methods
was high.
A thorough description of diets and weight provides a wealth of information.
Diets are currently being followed by 54 million Americans. e review of diets
begins with the famous self-selection diet experiment of Clara Davis in the 1920s
and 1930s. Children, from weaning until 6 years of age, were permitted to select
their meals from a wide variety of options. Davis reported that subjects chose to eat,
over time, pretty much exactly what they needed for growth and development. e
authors of e Gravity of Weight review this remarkable result, which had been ac-
cepted widely, including by me. ey show that Davis’s conclusion was not justified
by the details of the study; the actual freedom of choice of the children was greatly
constrained toward a healthy diet.
e section on diets opens a Pandora’s Box. e authors mention “thousands” of
publications on dieting, and it would seem that every possibility has been essayed:
high-fat diets, low-fat diets; high-carbohydrate diets, low-carbohydrate diets; high-
protein diets, low-protein diets; and so on. ere are diets associated with good
living: the South Beach diet, the Scarsdale diet, and the Beverly Hills diet. Diets are
also associated with their authors, as with Pritikin (low fat), Atkins (low carbohy-
drate), and Stillman (high water).
e benefits of this extravagant panoply have been limited. It is not clear that
any diet is any more effective than any other. e authors suggest two variables
involved in weight loss. ey are boredom with the diet, which leads to less con-
sumption, and boredom with calorie counting, which leads to weight gain.
xx THE GRAVITY OF WEIGHT
e section on pharmacotherapy for obesity describes the many medications
that are currently available. e Gravity of Weight concisely describes their charac-
teristics and problems. Only two, sibutramine and orlistat, have been well studied,

and they have been shown to be modestly effective and safe. e description of a
large number of less frequently prescribed medications is thorough and should be
useful for the practitioner.
A promising new agent, not yet approved by the U.S. Food and Drug Adminis-
tration, is rimonabant, a selective cannabinoid-1 receptor antagonist. It has been
used widely in Europe for many years, but concern about depression as a possible
side effect has interfered with its acceptance in this country.
e volume ends with a discussion of two very different surgical procedures.
One is liposuction, a cosmetic measure designed for “body sculpting” or “body
contouring.” Liposuction usually removes about 3 kilograms (6.6 pounds) of fat,
not enough to affect metabolic processes. Accordingly, the authors caution that
“liposuction definitely should not be considered a clinical treatment for obesity.” Li-
posuction is immensely popular; the number of procedures has risen from 100,000
in the 1980s to 400,000 in recent years. Its popularity is suggested by the report that
90% of liposuction patients would recommend it to other people.
Bariatric surgery is the second surgical procedure for obese persons. It is
designed for individuals with “morbid” obesity, a body mass index value of at least
40 kg/m
2
. e authors describe a number of reports on bariatric surgery, includ-
ing many that involve untoward events. Perhaps as a result, the authors are able to
contain their enthusiasm for this modality.
Several years ago, I studied a now outmoded surgical treatment of obesity and
found a number of favorable behavioral changes (Stunkard et al. 1986). Accord-
ingly, I was pleased to see reports of two large, well-controlled studies of bariatric
surgery. Sjöström et al. (2007) and Adams et al. (2007) described studies of 2,000
and 7,900 obese persons, over periods of 10 and 7 years, respectively. Large weight
losses were achieved as well as significant decreases in morbidity and mortality
compared with their control groups. My conclusion from these results is that bar-
iatric surgery is a highly specialized form of treatment and aftercare and that it

requires teams with extensive experience with the method.
Who is the audience for e Gravity of Weight? I was a natural member of this
audience, since the book deals so authoritatively with my long interest in obesity.
But what other people may be drawn to this book?
As psychiatrists, the authors naturally had in mind fellow psychiatrists when
they wrote the book. It should appeal to psychiatrists, not only because of its thor-
ough discussion of clinical issues but also because of the basic behavioral science
that is explicated in clear and well-written prose. Psychiatrists also often encounter
the obesity that is caused by psychotropic medications, the atypical antipsychotics
Foreword xxi
in particular. ey are in the best position to modify medication to minimize side
effects and maximize weight loss.
Other groups that should benefit from e Gravity of Weight are general prac-
titioners, internists, and psychologists who specialize in obesity. ese individuals
today provide most of the professional care for obese persons, and they should find
this volume particularly helpful. ey too will benefit from the excellent descrip-
tion of the basic science of obesity as well as the description of how to treat obese
people.
e Gravity of Weight is an authoritative account of obesity and its treatment. It
deserves a place in the library of those who work on this disorder.
Albert J. Stunkard, M.D.
Professor of Psychiatry and Founder and Director Emeritus, Center for Weight and Eating
Disorders, University of Pennsylvania School of Medicine
REFERENCES
Adams TD, Gress RE, Smith SC, et al: Long-term mortality after gastric bypass surgery.
NEngl J Med 2007 357:753–761, 2007
Florman DA: More on chewing gum (comment on Levine et al. 1999). N Engl J Med
342:1531–1532, 2000
Levine J, Baukol P, Pavlidis I: e energy expended in chewing gum. N Engl J Med 341:2100,
1999

Sjöström L, Narbro K, Sjöström CD, et al: Effects of bariatric surgery on mortality in Swed-
ish obese subjects. N Engl J Med 357:741–752, 2007
Stunkard AJ, Stinnett JL, Smoller JW: Psychological and social aspects of the surgical treat-
ment of obesity. Am J Psychiatry 143:417–429, 1986
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xxiii
A TALE OF TWO FATHERS
. . . almost everyone knows some very obese person who died very early, possibly as
the result of his or her obesity. At the same time, almost everyone knows some very
obese individual who lived a very long and healthy life.
Kevin R. Fontaine and David B. Allison,
Handbook of Obesity: Etiology and Pathophysiology (2004, p. 776)
During the writing of this book, my father, a retired orthopedic surgeon, died of
heart failure at the age of 91. Significantly, though, he had what we would consider
class 3 obesity, or morbid obesity, his entire adult life, except for the years when he
served in World War II and had to subsist on the army’s K rations. My mother used
to say my father had fought his own “Battle of the Bulge” his entire life. Because of
his obesity and his perpetual struggles with his weight, I had always expected him
to die fairly young. I would never have predicted that he would live into his 90s. In
fact, he outlived most of his nonobese friends, many of whom had actually died
years before.
My father had several of the risk factors that often lead to an earlier death,
including chronic heart disease, abdominal obesity, a poor cholesterol profile (i.e.,
dyslipidemia), hypertension, adult-onset diabetes, and even gout, all symptoms of
metabolic abnormalities. His own father had died at the age of 62 from a sudden
myocardial infarction, so my father had a strong genetic risk factor as well. What
was in my father’s favor, though, was that he had always believed in the importance
of exercise, particularly walking and weight lifting, well before it was fashionable.
He also never drank very much, and he never smoked. In fact, he instilled in my
brother and me the dangers of smoking well over 50 years ago, long before the

Surgeon General’s report.
Byram’s father, a writer and diplomat, conversely, had a more predictable demise.
He also had class 3 obesity, with fat predominantly accumulated in his abdominal
xxiv THE GRAVITY OF WEIGHT
area as well. But Byram’s father was 56 years old when, after a dinner of a large
omelet and lots of red wine, he died peacefully in his sleep after suffering a massive
myocardial infarction. He had loved his cigarettes and cigars and his imported red
wines, and he had never exercised. is was years before the availability of cardio-
thoracic bypass surgery, stents, or even medications for abnormal lipid levels or
hypertension.
Our fathers were worlds and cultures apart. My father lived most of his life in
the Philadelphia area. Byram’s father, born in Turkey, lived in France until he and
his family fled back to Turkey during the Nazi occupation of France during World
War II. eir lives, though, enable us to appreciate just how unpredictable—and
even seemingly capricious—the consequences of obesity can be and how much we
still do not know about the complex subject of weight. Statistics can never account
for everyone.
Nevertheless, our book, e Gravity of Weight: A Clinical Guide to Weight Loss
and Maintenance, is our attempt to explain some of these discrepancies and ex-
plore particularly why, for most people, it is so difficult to lose weight and maintain
that loss. No one has all the answers, but an understanding of the science, of both
mind and body, behind these complexities is a beginning. It is to our fathers that
our book is dedicated.
Sylvia R. Karasu, M.D.
REFERENCES
Fontaine KR, Allison DB: Obesity and mortality rates, in Handbook of Obesity: Etiology
and Pathophysiology. Edited by Bray GA, Bouchard C. New York, Marcel Dekker, 2004,
pp767–786
Hill AB: e environment and disease: association or causation? Proc R Soc Med 58:295–
300, 1965

Moore-Ede MC: Physiology of the circadian timing system: predictive versus reactive ho-
meostasis. Am J Physiol Regulatory Integrative Comp Physiol 250: R737–752, 1986