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Weighing the Facts

A Psychiatrist Parses the Often Bewildering Literature on Obesity

Dr. Sylvia Karasu and her husband both had fathers who were morbidly obese. The two men — Dr. Karasu’s dad was an orthopaedic surgeon in the Philadelphia suburbs, her father-in-law a writer and diplomat in Turkey — suffered serious medical consequences from their weight including adult-onset diabetes, chronic heart disease and hypertension. But Dr. Karasu’s father-in-law died at 56, while her dad lived to 91. “That juxtaposition fascinated me,” says Dr. Karasu, a clinical professor of psychiatry at Weill Cornell Medicine. “How is it possible that one condition can lead to those extremes in lifespan?”

This question continues to drive much of Dr. Karasu’s work. In addition to running a private psychiatry practice with a focus on patients in the creative and entertainment fields — in which she treats numerous people who struggle with disordered eating — she writes about health and obesity from a vantage point that’s quite different from that of an internist or endocrinologist. She doesn’t conduct independent research on the condition, which affects 30 percent of Americans and is considered a worldwide pandemic. Instead, she pores over the hundreds of scientific articles that are published each month on obesity, thinks critically about what she reads, and then categorizes and distills the research findings. The results of this work include four articles in peer-reviewed journals and a regular column for psychologytoday.com, having published more than 75 blog posts and counting. “My goal is to educate both the lay public and medical professionals on obesity’s complexities, what I call the ‘daunting science of weight control,’ ” Dr. Karasu says, “so that they take a more nuanced — rather than narrow — view of this condition.”

Dr. Sylvia Karasu. Photo by Glenn Jussen

Before starting her column, Dr. Karasu explored some of these complexities in a 2010 textbook for medical professionals, “The Gravity of Weight: A Comprehensive Approach to Weight Loss and Maintenance,” that she co-authored with her husband, Dr. T. Byram Karasu, the Silverman Professor and chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine/Montefiore Medical Center. (The couple also co-wrote the 2005 book “The Art of Marriage Maintenance.”) Since then, she has continued to parse research online, covering such topics as why “fat shaming” doesn’t motivate people to slim down; how breastfeeding — or being breastfed — can impact weight; and why the popular paleo (for Paleolithic) diet is a sham, since “most of the foods available to us today are vastly different from those eaten in Stone Age times.”

In the articles she has published in peer-reviewed journals, including American Journal of Lifestyle Medicine and American Journal of Psychotherapy, Dr. Karasu has addressed such issues as the role of the mental health practitioner in weight loss and how experts define obesity in often conflicting and contradictory ways, depending on their background or academic specialty. “Physicians see obesity as a medical issue, psychiatrists might see it as an addiction issue, and anthropologists see it as a disease of civilization,” Dr.  Karasu says. And it only gets more complicated, as some people think obesity is just body diversity and therefore natural, while others believe it’s caused by environmental factors; some think obesity is largely rooted in genetics, while others attribute it to vices like sloth and gluttony, Dr. Karasu says.

That connects back to the underlying reason why, Dr. Karasu believes, her father and father-in-law had such different outcomes: obesity is not one single condition. “There’s as much variation when it comes to obese and overweight people as there is in the general population,” Dr. Karasu says. Yet we tend to lump together everyone with a body mass index over 30.0, an arbitrary figure calculated by taking a person’s weight in kilograms divided by their height in meters squared. When we do so, she says, we make false generalizations, unfairly stigmatize people, and oversimplify what’s going on, which can make it more difficult to find solutions. That’s why she’s advocating that medical professionals and society in general, adopt a new way of thinking about obesity. “We should stop talking about it as if it’s one disorder or disease,” Dr.  Karasu says. “It should be ‘the obesities,’ plural.”

— Anne Machalinski

This story first appeared in Weill Cornell Medicine, Vol. 16. No. 2

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