Despite Bruch’s research linking childhood obesity to overeating and pathologies in the mother-child relationship, she was all too aware that her own research had failed to establish what was cause and what was effect. Her research had been uncontrolled, she noted, because she had studied only obese children and their families. “The literature on behavior disorders in childhood abounds with references to maternal rejection and overprotection,” she explained. There was no way to know whether what she had discovered about her obese subjects actually played a major role in the development of obesity. It was also possible that the children had a predisposition to fatten and that this affected the children’s desire to eat to excess, which in turn affected the family dynamics and how the families treated the children. What appeared to be a cause could in fact be an effect. “Life situations and emotional experiences of this kind,” Bruch wrote, “provoke increased desire for food only in a certain type of person and result in obesity only when such a person has a special tendency to store fat in larger amounts than others and does not increase the energy expenditure correspondingly.”

After publishing her observations on childhood obesity, Bruch put aside her clinical practice temporarily to study psychiatry, in the hope of helping these children. Through the early 1960s, she practiced psychiatry in New York, and then took a position as professor of psychiatry at Baylor College of Medicine in Houston. Throughout this period, she continued to specialize in anorexia and obesity. In 1957, with the publication of The Importance of Overweight, she was still questioning the role of psychological factors in obesity. (She described the book as a “critical re-evaluation and reintegration” of the obesity literature, including her own research.) Bruch couldn’t escape the fact that restricting calories failed to bring obesity under control for any extended period of time, and she was simply unwilling to blame such consistent failure on her patients or their upbringing. “The efficacy of any treatment of obesity can be appraised only by the permanence of the result,” Bruch stated. “When I began to work with obese children,” she wrote, “I was impressed by the seeming ease with which some were able to lose weight once I had gained their co-operation. Having followed such cases over twenty years, I am today even more impressed by the speed with which they will regain the lost weight and by the tenacity with which they maintain their weight at an individually characteristic high level. It is possible to force the weight below this individual level, but such efforts are usually short-lived.”