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.
At this point, we could discuss how a culture that fetishizes food affects the standard American diet, and how political influence in the food industry exerts power over what kinds of food are made available and affordable. We could compare the nutritional value of what we eat today to what our parents ate. Or we could look at what is currently understood about the genes that influence the hormones, which then influence other processes to make this a repeating pattern. But these discussions go beyond the scope of this article. Interested readers can pursue these topics with the provided resources.
An abbreviated version is this: a combination of factors, which include genetics, high-calorie diets, and sedentary lifestyles, leads to metabolic changes that promote the storage of excess nutrition in fat cells. This situation is difficult to reverse for many reasons, and it can have a negative impact on general health.

Complications

Not all people who are overweight are unhealthy, but there is a statistical link between obesity and the risk of certain complications. People who are obese have a four times greater risk of mortality related to heart attack or stroke than the general population, and a two times greater risk of developing cancer, especially breast, colon, lung, gallbladder, prostate, or endometrial cancer.
Other conditions that are seen more frequently in this group include: hypertension, gallstones, asthma, cellulitis, atherosclerosis, nonalcoholic fatty liver disease, hypoventilation syndrome, boils, cardiomyopathy, gastroesophageal reflux disorder, polycystic ovaries, joint pain, varicose veins, sleep apnea, pregnancy-induced hypertension, or depression.
All these disorders, and the medications clients may use to treat them, have repercussions for massage therapy. As with all our clients, we need to gather a thorough health history to be sure our intervention is safe. Of special note here are sleep apnea (lack of good quality sleep changes metabolism and promotes weight gain, so there’s a vicious circle); boils and cellulitis (skin problems are potentially infectious and carry cautions for massage therapy); and joint pain (joint pain brings a lot of people to massage therapists, so this is something we can anticipate). Finally, depression and isolation are important factors in the quality of life of people who live with obesity.

Accommodations in Massage Therapy

Human beings crave welcomed, safe, nonsexual touch. Without it, we cannot thrive. Sometimes, we may try to replace the vital “food” of healthy touch on our outer skin with the snug, safe, sated feeling of filling up with literal food—an internal hug, if you will—and this habit, among several other factors, leads to problems. People who are overweight and obese often feel isolated, ostracized, and touch-avoidant, but they can derive great benefit from carefully and skillfully applied massage therapy, with appropriate accommodations.

Massage Table Weight Capacity

Most standard portable massage tables can handle up to 500 “working pounds” of pressure—that is, the weight of the client, plus the downward and moving force exerted by the therapist. Sturdier tables are available, and they are an important investment for plus-size clients. (That said, it is important to point out that lots of tables break under the weight of clients who are not obese. Sometimes table breakage is an issue of maintenance and structural integrity, not of a client’s weight.)

Furniture

Another often-neglected adaptation for larger clients is the furniture in waiting rooms. Do all your chairs have arms? If they do, are they wide enough to comfortably accommodate a person who is obese? If not, consider adding a couple of armless chairs to your office.

Client Positioning

People who are overweight may have breathing difficulties and low-back pain while supine. And being prone can be uncomfortable for women of any size if they have large breasts. Extensive bolstering can help, and a table with breast recesses is useful too. Arm extensions are a popular add-on that are much appreciated by large clients. Some therapists find that doing a lot of work with the client in a side-lying position is a good option too.

Linens

Typical massage table sheets may not provide adequate coverage, especially when a client turns over. Some therapists recommend using a full-size or queen-size top sheet for clients who are bigger than average.

Technique

Clients who live with obesity also require accommodations in technique. Bony landmarks are less obvious, so we need to be more sensitive to subtler signals about anatomy. While many massage therapists assume that clients who are overweight require more pressure for massage to be effective, the opposite is often true: many people with this body type are extremely sensitive to touch and easy to overtreat. And as we’ve discussed, these clients are at risk for cardiovascular problems, diabetes, and many other challenges, so we need to know what medications they use, if they’ve had surgery, and what side effects and other repercussions of treatment they experience. This is a topic we will discuss in part 2 of this series.

Communication

In my opinion, the most important accommodation a massage therapist can make for a client who struggles with obesity is to take care in the way we communicate—verbally and nonverbally—about our client’s body. It is easy to fall into the “I always give wellness advice to my clients” kind of attitude, but I promise you our overweight clients know they’re overweight—they don’t need anyone to point it out. What they need from us is an opportunity to have a positive physical experience that celebrates their wonderfulness and that helps them meet their goals (not ours). They don’t need a lesson in nutrition or exercise unless (a) they ask for it, and (b) we are qualified and credentialed to give such counseling. So instead of, “Have you tried the  supplement or  exercise?” maybe we can switch to a message like, “I’m glad you’re here. Let’s have a really great session.”

My entire life I’ve had to deal with people intentionally or unintentionally rolling their eyes at me. They think I’m not healthy, I’m unhygienic, I’m lazy.”
—Marcy Basile, LMT, massage therapy instructor, personal trainer
 
Massage therapy—by definition safe, welcomed, nonsexual touch—can help fill the need for human connection. We can have a powerful, positive influence on a person’s physical experience, just by creating an hour when our client can feel cherished, precious, and beloved. Many obesity treatment protocols call for nonfood rewards—it’s hard to imagine a better reward than massage.
I urge readers of this article to consider how they can be of service to this population of touch-starved people. What will you do to meet the needs of your clients who are obese?

Resources

American College of Cardiology. “Obesity: Pathophysiology and Management.” January 4, 2018. Accessed May 2018. www.acc.org/latest-in-cardiology/ten-points-to-remember/2018/01/04/16/16/obesity-pathophysiology-and-management.
American Medical Association. “AMA Adopts Policy to Help Physicians, Students Prevent, Manage Obesity.” June 14, 2017. www.ama-assn.org/ama-adopts-policy-help-physicians-students-prevent-manage-obesity.
American Society for Metabolic and Bariatric Surgery. “Disease of Obesity.” Accessed May 2018. www.asmbs.org/patients/disease-of-obesity.
Bray, G. A., Kim, K. K., and Wilding, J. P. H. “Obesity: A Chronic Relapsing Progressive Disease Process. A Position Statement of the World Obesity Federation.” Obesity Reviews 18, no. 7 (July, 2017): 715–23. https://doi.org/10.1111/obr.12551.
Centers for Disease Control and Prevention. “Defining Adult Overweight and Obesity.” Accessed May 2018. www.cdc.gov/obesity/adult/defining.html.
Fryhofer, Sandra. Report of the Council on Science and Public Health: Report 3-A-13. www.ama-assn.org/sites/default/files/media-browser/public/about-ama/councils/Council%20Reports/council-on-science-public-health/a13csaph3.pdf.
Hamdy, Osama. Medscape. “Obesity.” Last updated March 20, 2018. Accessed May 2018. https://emedicine.medscape.com/article/123702-overview.
Massage Business Blueprint. “E131: Working with Larger Massage Clients (with Marcy Basile).” Podcast. Accessed May 2018. www.massagebusinessblueprint.com/podcast/e131-working-larger-massage-clients-marcy-basile.
McCall, Becky. Medscape. “Call for More Countries to Recognize Obesity as Disease.” May 24, 2017. Accessed May 2018. www.medscape.com/viewarticle/880560.
National Heart, Lung, and Blood Institute. “Calculate Your Body Mass Index.” Accessed May 2018. www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
Obesity Medicine Association. “American Medical Association House of Delegates Approves Resolution to Help Destigmatize Obesity.” June 13, 2017. www.obesitymedicine.org/ama-destigmatize-obesity-resolution.
Obesity Prevention Source. “Ethnic Differences in BMI and Disease Risk.” Accessed May 2018. www.hsph.harvard.edu/obesity-prevention-source/ethnic-differences-in-bmi-and-disease-risk.
Redinger, Richard N. “The Pathophysiology of Obesity and Its Clinical Manifestations.” Gastroenterology & Hepatology 3, no. 11 (November 2007): 856–63. www.ncbi.nlm.nih.gov/pmc/articles/PMC3104148.
World Health Organization. “Obesity and Overweight.” Last updated February 2018. Accessed May 2018. www.who.int/mediacentre/factsheets/fs311/en.

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at BooksofDiscovery.com), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.