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44 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 8 diarrhea, and/or constipation, which I treat with herbal tea suggested by the bariatric surgeon. Water intake is important, and (the worst thing for me) I can have no caffeine—because caffeine leaches calcium from the bones, so I'd be at risk for osteoporosis. I must be vigilant in taking vitamins, because one of the most dangerous complications after bariatric surgery is a lack of absorption of essential nutrients. People who have had bariatric surgery are warned against drinking alcohol. Because the digestive process takes less time, alcohol puts us at high risk for liver damage or cirrhosis. Exercise is strongly encouraged, as is attending some kind of accountability-based eating control program like Weight Watchers or Overeaters Anonymous. So, I'm human. I screw up sometimes. I eat the wrong things. My body keeps screaming for sugar, and I'm actively working on my grazing behaviors. I forget my water, and drink caffeinated beverages once in a while. When that happens, I look at my "before" picture and return to better habits very quickly. I've kept the weight off now for three years, and I feel the best I have in a very long time. IMPLICATIONS FOR MASSAGE THERAPY Bariatric surgery is not a single event. It's a multistep process of preparing for surgery, having the procedure, short-term recovery, and long-term results. Each of those steps requires different approaches with massage. For clients who are presurgery, positioning with multiple supports and pillows will allow the person to relax. Practitioners trained in lymphatic drainage may find that presurgical lymphatic work can be extremely helpful in postsurgical healing. More on working with clients who are obese can be found in Part 1 of this article. Postsurgical massage should be done with the consultation of the surgical team, assuming the client is open to having you communicate with their doctors. A simple When a person who has had bariatric surgery makes an appointment for massage therapy, we need to anticipate certain needs. We also need to be f lexible and teachable: our clients will know much more about their situation than we can. Impairments to decision-making processes and the acknowledgment of predictable consequences seem to be altered in those with obesity. Some aspects of frontal lobe activity and poor impulse control that are usually associated with people who have attention-deficit/ hyperactivity disorder seem to be a part of the picture. 2 Neuropsychological studies support the hypothesis that a breakdown of executive function can lead to altered inhibitory control and poor emotional regulation to make sound behavioral choices. Evidence shows that brain patterns of those living with other types of addiction (e.g., sex addiction or gambling) share neural patterning and impaired regulation of dopamine receptors with disordered overeating. 3 These findings contribute to the body of knowledge about why it is so hard to lose weight and keep it off. Bariatric Surgery Bariatric surgery shows promising results for long-term weight loss. About 75 percent of people with severe obesity (BMI of 40 or higher) who undergo surgery eventually lose and keep off 50 percent or more of the excess weight. Bariatric surgery is an extreme choice, and it is far from risk-free. The screening process is stringent and may rule out many candidates. A comprehensive treatment program includes nutritional and psychological counseling in addition to surgery, to make sure the person can adhere to a long and often difficult journey. LISA'S EXPERIENCE Obesity is a global issue and a threat to our national health. When I learned about the contributions of genetic disposition and neurotransmitter reception, I began to understand obesity as an illness rather than as a failure of willpower. This changed my perspective, even on my own struggle with weight. In 2014, I found myself weighing much more than I could live with. I had spent most of my life as a fat person (that word is my personal preference). I had a respite before I had children, when I was able to maintain a more athletic appearance. But my gene pool, new-mom exhaustion, habits, postpartum health issues, and an interesting health history all affected my ability to lose weight. My health was beginning to suffer. When my doctor suggested I think about bariatric surgery, I was extremely skeptical. The three-month screening process convinced me that I was a good candidate, because I loved to exercise and already had fairly healthy eating habits—my issue was more about volume of food than content. For me, the initial Roux-en-Y gastric bypass recovery was swift in terms of discomfort, but the longer-term changes continue to be a challenge. I regularly have intestinal gas,