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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 13 READER FORUM DEMYSTIFYING OBESITY I read Ruth Werner's article "Demystifying Obesity" [Massage & Bodywork, July/August 2018, page 40] with great interest and some trepidation. I read a lot about fatness from a nonmedical perspective, and have seen how contentious the link between obesity and health risks can be, even within the body positivity movement. There are such high emotions on all sides of this topic, from those who promote body acceptance for all to those who judge larger bodies harshly. This is a topic where "you can't please all the people all the time" is at its truest. I tend to trust Ruth Werner as a voice of reason, but, as a fat person myself, I was concerned about the potential for pathologizing a body type. Reading the article, I realized that Ruth, as a trusted voice on pathology, was actually very well positioned to write about this topic. She walked the tightrope of addressing a contentious topic with grace and did a great job of explaining how obesity works without stigmatizing or shaming. She laid out potential complications but made clear that these should never be assumed based on appearance. I see a lot of judgement and inadvertent body shaming in discussions of obese clients among massage therapists. The last thing we should be doing is saying that some bodies are less worthy than others or creating an environment that drives away obese clients who could really benefi t from touch, and the accommodations laid out in the article can help therapists avoid doing exactly that. Kudos to Massage & Bodywork and to Ruth for kickstarting an important discussion in such a measured way. I look forward to reading Part 2! MEGAN SPENCE BROOKLYN, NEW YORK A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 41 40 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 8 education PATHOLOGY PERSPECTIVES Demystifying Obesity Looking Beyond the Scale, Part 1 By Ruth Werner It is with a great deal of trepidation that I approach the topic of obesity in a pathology column. "Oh, there she goes, pathologizing a behavior. Aren't there enough real diseases to discuss?" I can hear some readers say. "Obesity is a disease now? There's a simple, cheap cure: eat less and get off your ass," I have heard from others—including medical professionals. The American Medical Association declared an opinion on this matter in 2013: in the United States, obesity is now considered to be a freestanding disease. The Canadian Medical Association, the World Health Organization, and the World Obesity Federation have all followed. This article will be a two-part effort. In this edition, we will look at the background information about obesity, what repercussions it has on general health, and some important accommodations in the massage therapy session room for clients who are overweight or obese. Next time, we will explore treatment options for obesity, including diet, exercise, drugs, and surgery, with emphasis on massage therapy accommodations for people who are going through treatment for this condition. I want to thank in advance the many people who have contributed to these articles; your wisdom and generosity are much appreciated. WHAT'S IN A NAME? Obesity. The word is both a diagnosis and a descriptor that carries an undeniable and pejorative value judgment. In simplest terms, obesity means being substantially heavier than is considered to be healthy for a person's height: it is a mathematical, objective reality. But in cultural terms, the word obesity can be an accusation of weak character, self-indulgence, laziness, and worse. "Marvelous, gluttony becomes a disease. What's next?" —Pharmacist, during a public discussion of obesity for medical providers The World Obesity Federation defines this condition as "a chronic, relapsing, progressive disease process." The American Association of Clinical Endocrinologists suggests a new label: adiposity-based chronic disease (ABCD). This is an attempt to steer attention toward the pathophysiology of this condition and away from associated value judgments. DIAGNOSIS AND STATISTICS The body-mass index (BMI) is a formula used to describe a person's weight/height ratio. Statistically, we can predict an increased risk for certain complications when people have high BMIs, but these numbers are notoriously imprecise, especially at the lower end of the overweight spectrum. Tall and proportionate people or large and very athletic people may have "high" BMIs and still be healthy and fit, for instance. Also, BMI-related risk profiles show some racial disparities. For whites, the lowest risk of weight-related complications is with a BMI under 30, but for blacks the risk starts sooner: their target is under 25. Asians' optimal weight is lower still, with variances for specific ethnic origins. "I hate that every time I visit the doctor, or even a massage therapist, I am automatically seen as a walking risk factor. Well, I bet my blood pressure, my cholesterol, and my A1C readings are better than yours." —Ann Blair Kennedy, DrPH, athlete, and clinical assistant professor at University of South Carolina School of Medicine, Greenville Tools other than the BMI to determine obesity or the percentage of body fat exist, but in the United States it is the main diagnostic criterion for obesity, following these guidelines: BMI 18.5–24.9 Optimal weight 25–29.9 Overweight 30–34.9 Class 1 obesity 35–39.9 Class 2 obesity 40 or higher Class 3 obesity Obesity is an important health problem in the United States and other industrialized countries. In 2017, it was estimated that 31.4 percent of the population over age 20 in the United States were obese (that's 78 million people), and that number continues to grow at an alarming pace. We spend almost $200 billion a year on this situation—and this does not include the $121 billion spent on weight-loss products. A person with this condition incurs almost $3,000 more in health costs each year than a person who is not obese. PATHOPHYSIOLOGY: WHAT DO WE UNDERSTAND ABOUT OBESITY? Obesity is clearly the result of taking in more energy in the form of calories than is expended in the work of daily activities, but the process and its repercussions are extremely complicated. Other factors, including the types of calories consumed, how well a person sleeps, levels of stress and distress, medications, and even what kind of neighborhood a person lives in, can all have influence on weight gain and barriers to weight loss. Fat cells, or adipocytes, are distributed all over the body. The two places we are most interested in are the abdomen (central fat) and the superficial fascia (peripheral fat). We used to think of fat cells as passive storage tanks, but we know now that they are metabolically active, and they secrete a vast array of hormones and other chemicals. For this reason, obesity is often discussed as an endocrine system issue. The secretions that fat cells produce, especially those in the abdomen, are pro-inflammatory, promote blood coagulation, and influence insulin sensitivity and appetite regulation. As we have learned more about adipocytokines (chemicals secreted by fat cells), we have come to understand that obesity becomes a self-sustaining condition. In other words, once a person's physiology and internal chemistry has changed, it becomes increasingly difficult to reverse that change. Eating less food makes metabolism slow down—no weight loss. In fact, dieting is a recognized contributor to obesity. Moderate exercise has less impact on calorie burning for this population. The sense of appetite changes: people who are obese are less sensitive to the hormones that signal satiety (having had enough to eat). Even the sense of smell (which triggers appetite) is often stronger in people who are overweight than it is in others. Experts who study obesity in the United States and around the world have compiled a long list of contributing factors, some of which overlap each other. These include: metabolic factors, endocrine factors, socioeconomic factors, psychological factors, genetic factors, race, sex, age, dietary habits, pregnancy and menopause, level of physical activity, ethnic and cultural factors, smoking cessation, or history of gestational diabetes. Let us know your thoughts about the magazine! Email I'd like to add a couple of points to the discussion of obesity and the article in the July/August 2018 issue of Massage & Bodywork magazine. Some obese clients may have lymphedema or lipedema, or both. And some may not know it. Neither disease is a result of too many calories taken in or too little exercise. Also, while the specifi cs are not fully understood by the medical community as of yet, lymphedema can create its own fat cells. Therapists need to know the signs of both diseases and how to treat these clients. JULIA MORROW NORTHRIDGE, CALIFORNIA Author response Julia Morrow is absolutely correct: lymphedema and lipedema are occasional complications of obesity. I should have included these in the discussion of obesity-related problems. Further, while I was skeptical of the claim that lymphedema can actually lead to having more fat cells in the affected areas, I found some research that supports this claim. Evidently in some circumstances, local macrophages drawn by infl ammation can transform into adipocytes. I am happy to be educated, and glad that Massage & Bodywork magazine has such well-informed readers. RUTH WERNER ARE YOU A PLACEBO? I felt the need to offer my thoughts about Til Luchau's excellent article "Are You a Placebo?" [ July/August 2018, page 80]. It is hands down (pun intended) one of the most useful ABMP pieces to come by in quite some time. In addition to our hard-earned skills, continuing education, and thirst for clinical/ anatomical knowledge, let us never forget that it is our intention, caring, warmth, and healing hands that are of greatest importance. I've been at this gig for 14 years, performed more than 10,000 paid client sessions (and countless other of the "spot" and gratis variety!), and I can honestly say that my clients equally appreciate my honesty, my ability to locate the source of their discomfort, and the power of my touch. And I dare say that they could care less whether or not I know the insertion/ origin/action of the brachioradialis; all they know is that I always, always make them feel better. MARK MONTIMURRO MONTCLAIR, NEW JERSEY HOW PAIN CHANGED HER LIFE I just read Cindy Williams's article "How Pain Changed My Life for the Good" in the Massage & Bodywork May/June 2018 issue [page 74]. I want to tell you how deeply touched I am by her story of trauma and of physical and spiritual recovery. She brought me to tears. SARAH WALDHORN PHILADELPHIA, PENNSYLVANIA

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