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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 43 field. Santoro founded the massage practice at Harvard University, she was the director of massage programs at Boston Medical Center, and now does pediatric massage at the Lucille Packard Children's Hospital at Stanford. She is a longtime massage therapy instructor and a contributing author to multiple textbooks. Santoro will share some of her research, experiences, and suggestions for massage therapy accommodations for people who have had bariatric surgery. WEIGHT-LOSS TREATMENT OPTIONS With about two-thirds of the US adult population overweight or obese, it is not surprising that weight-loss treatments are a booming industry. Americans spend about $66 billion each year on weight-loss programs, meal replacements, medical weight-loss clinics, and surgery. And yet, as a country, we are fatter than ever, and the need to limit the risk of life-threatening diabetes, heart disease, and other complications grows daily. Nonsurgical weight-loss options can be intimidating. A short list includes: • Diet and exercise: This is obviously a first strategy, but for reasons discussed in the previous article, diet and exercise are sometimes insufficient to reverse obesity. In fact, a history of frequent dieting increases the risk of intractable obesity. This is not to say that long- term weight loss through diet and exercise is impossible. But adults who are able to lose weight and keep it off are the exception rather than the rule. • Anti-obesity drugs: A variety of drugs to fight obesity have been developed, but many doctors agree that these are an underused resource, for several reasons. These drugs have several mechanisms. They can interfere with fat absorption, affect the appetite center in the brain, or alter the dopamine system in the central nervous system for reward-driven behaviors. • Bariatric arterial embolization: This is a new intervention in which the gastric artery that delivers blood to the stomach is blocked with tiny pellets. This inhibits the secretion of ghrelin, a hormone that signals hunger, so that food cravings are limited. • Endoscopic intragastric balloon: 1–3 inflated silicon balloons are inserted into the stomach and left for six months. These take up space in the stomach and decrease the amount of food that can be ingested. Surgical options are likewise daunting to consider: • Gastric bypass (Roux-en-Y): A small pouch is created from the stomach, and the small intestine is attached directly to it. Reduced stomach capacity and a shorter small intestine means less food can be consumed and absorbed. Gut hormones that influence hunger and satiety are also changed. • Sleeve gastrectomy: This procedure removes about 80 percent of the stomach. At the same time as decreasing capacity, this intervention also seems to have a positive impact on gut hormones that influence hunger and satiety. • Adjustable gastric band: An inflatable band is placed around the stomach. It can be adjusted over time, using sterile saline that is injected through a port under the skin. This procedure has a higher rate of complications and a higher chance of unsuccessful weight loss than the sleeve or bypass surgeries. • Biliopancreatic diversion with duodenal switch: This procedure is roughly like a combination of the Roux-en-Y and sleeve gastrectomy: most of the stomach and the small intestine are removed, and this decreases the amount of food that can be consumed and the amount of calories that can be absorbed. It is the most complex of the surgeries, but it has the best outcomes for people who are diabetic. ASSOCIATIONS BETWEEN OVEREATING, ADDICTION, AND ADHD Dopamine is the main neurotransmitter that is tied to feelings of pleasure and reward. It floods us with positive emotions when we fulfill a biological need. 1 Addictive substances and behaviors can stimulate fluctuations in dopamine release. In some circumstances, the brain receptors responsible for dopamine release require more stimuli to achieve the same level of satisfaction. A similar process happens with some people and food: when these people overeat, a down-regulation of receptors throws the system into negative overdrive. The more they eat, the less dopamine they secrete in response. This vicious cycle compels the person to eat even more—and this compulsion overcomes any other messages about satiety or biologically based feelings of fullness. Further, because dopamine sensitivity and other neurotransmitter activity patterns are genetically inherited, people with obesity are especially vulnerable to this pattern, while others can manage their appetite with little effort. When people who are genetically predisposed toward obesity try to limit their caloric intake, withdrawal symptoms begin. Then, stress reactions increase food cravings. In other words, these people are both hungry and extra-stressed about not meeting a neurologically driven need for stimulation, which makes them feel even hungrier. Delayed, and/or difficulty in decision making, self-control, and regulatory processes of executive function lead to repeated relapse. Add negative emotions (e.g., failure to resist temptation, a feeling of moral weakness) to the mix and those factors steer people back toward the behaviors they hope will create pleasure— i.e., eating. This ever-increasing drive toward relapse is almost inevitable, even in the most determined and dedicated person who is desperately trying to lose weight.