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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 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. Yo u r M & B i s w o r t h 2 C E s ! G o t o w w w. a b m p . c o m / c e t o l e a r n m o r e . 13 THE PURSUIT OF KNOWLEDGE I was so excited to read the "Pain Points" article by Ben Benjamin [May/June 2018, page 60]. I have been a massage therapist for about fi ve years, and I have been increasingly appalled by the skill level of most therapists I come across—and let's be honest here: this includes myself. So many clients come to a massage therapist thinking the therapist is trained to deal with pain when the simple truth is that we are not trained for this. But in order to present ourselves as capable and successful, we are trained to try to convince clients we can help them. Many times, we can, but for me this does not make up for the fact that most of us are not as skilled as we believe ourselves to be. When I went to massage school, this is what I hoped to learn. I was disappointed when the "medical massage" portion of my program turned out to essentially not exist. And so, after graduating, I have tried to seek out trainings to correct this and gain the skills that Benjamin talks about. But I have had a hard time fi nding places to learn this well, and have ended up being a spa therapist because I feel it's unethical to promote myself otherwise without the skills listed in the article. When I read Massage & Bodywork, it seems like some highly skilled therapists write these articles, but among the 200 MTs I know, none of us have these skills; does ABMP realize this lack of education likely exists in the majority of their readers? Please, assume we know less than you think we do! I want so badly to learn more, please help! JESS MAGGI TAOS, NEW MEXICO Editor's response Thanks for your feedback Jess. We appreciate that readers come from a variety of backgrounds and learning styles, some with more classroom training than others, some with degrees in complementary fi elds, and some with more OPENING THE CONVERSATION Happy summer! I wanted to reach out and say thank you for the article "Demystifying Obesity: Looking Beyond the Scale, Part 1" by Ruth Werner [ July/August 2018, page 40]. This is an incredibly important topic and this article really hit home. I often think I went into bodywork as a way to heal my own issues with body image. I have always made it a priority in my practice to create a "no-judgment zone" and have worked hard to make my massage space as comfortable and accessible as possible. Investing in a wider table or table extenders and offering side-lying options and breast and belly support options can make the world of difference to an obese client seeking massage. I have had many clients comment to me that they have never been on a table before mine that they could lie comfortably on and that it was so nice to feel like they "fi t" on the table. This article really opens up the topic of conversation for therapists to learn from, and the more we work together to make our spaces the best for all clients, the more we can continue to do the work the world needs. Thank you! ERICA KEAY GLENS FALLS, NEW YORK desire than others for continuing education. That is largely why our publications try to offer a spectrum of content: from entry-level to mastery. As for opportunities to explore the more technical skills of your profession, there are several options, including our ABMP Continuing Education Library (abmp.com/ ce) where ABMP members have a vast library of continuing education to choose from (and earn free CE credits), as well as a Continuing Education Calendar showing events around the country (www.abmp.com/members/calendar_ ce.php). Whether looking for local classroom opportunities or national events presented online, you can fi nd a learning opportunity that fi ts your needs. And don't forget to look within the pages of this magazine. Our advertisers offer a wealth of educational opportunities for those looking to expand their practice knowledge.