In my previous Pathology Perspectives column (Massage & Bodywork, July/August 2018, page 40), we introduced the condition of obesity as a freestanding disease. The American Medical Association, the World Health Organization, and many others support this view. The World Obesity Federation describes obesity as “a chronic, relapsing, progressive disease process.” The American Association of Clinical Endocrinologists suggests changing the name from obesity to “adiposity-related chronic disease.” This label and description capture an important aspect of obesity: it is a chronic condition, meaning it is long-lasting, progressive, and difficult—if not impossible, for some people—to permanently correct through diet and exercise alone.
In this column, we will look at common treatment options for obesity, with a focus on bariatric surgery. Much of this column will be carried by my friend, colleague, and veteran of bariatric surgery Lisa Santoro, a certified massage therapist and lymphatic specialist. Santoro is currently getting her psychology degree with a minor in nutrition. She will be working in the postbariatric surgery 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.
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, 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 letter describing how you work and the primary goals in your massage therapy sessions can open this dialogue, as you invite the team to share any questions or concerns.
The abdominal area will be sore for quite some time—several weeks or more—so side-lying or semi-supine may be the best table position for your client who is recently postbariatric surgery. Elevating the legs can also help with any extremity swelling. Because of the abdominal digestive revision, the lymphatic pathways will be going through a rerouting process, and some fluid backup can be expected. As the person rapidly sheds their presurgery weight, skin changes can be expected, especially in texture and elasticity. Excess skin is a by-product of the weight loss, so strokes like long-drag Swedish effleurage may need extra lubrication. Some patients will go through follow-up body-contouring surgery to remove excess skin, and this requires different accommodations for massage therapy.
It’s hard to foresee where and what kind of massage will best suit a person who has been through bariatric surgery. One predictable challenge is how posture changes as the weight comes off. Overweight people are likely to have back pain, along with neck and shoulder pain. They may also have foot issues like plantar fasciitis or flat feet that persist after weight loss. Other physical symptoms will vary, and it is the practitioner’s job to address these on a case-by-case basis. Massage therapists can contribute to a positive outcome by developing a long-term focused treatment plan that supports the physical transformation of their bariatric client. While Lisa went through her rapid, and then more manageable, weight loss, massage helped her get in touch with changing postural needs and encouraged a positive self-image. It was—and is—an important part of her recovery process.
In conclusion, 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 flexible and teachable: our clients will know much more about their situation than we can. When we engage our clients in teaching us, and work together to design their perfect session, we invite them to long-term self-care with massage. This is a wonderful gift for all of our clients, especially those who, like people who have chosen bariatric surgery, are deeply invested in their own well-being.

Resources

American Society for Metabolic and Bariatric Surgery. “Bariatric Surgery Misconceptions.” Accessed June 5, 2018. www.asmbs.org/patients/bariatric-surgery-misconceptions.
American Society for Metabolic and Bariatric Surgery. “Bariatric Surgery Procedures.” Accessed June 11, 2018. www.asmbs.org/patients/bariatric-surgery-procedures.
Bond, D. S. et al. “Weight-Loss Maintenance in Successful Weight Losers: Surgical vs Non-Surgical Methods.” International Journal of Obesity 33, no. 1 (January 2009): 173–80. https://doi.org/10.1038/ijo.2008.256.
Gloy, Viktoria L. et al. “Bariatric Surgery versus Non-Surgical Treatment for Obesity: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.” BMJ 347 (October 22, 2013): f5934. https://doi.org/10.1136/bmj.f5934.
Kahan, S. “Quick Takes: What You Need to Know About The 5 FDA-Approved Obesity Drugs.” Medscape. March 2, 2017. www.medscape.com/viewarticle/876411.
MarketResearch.com. “U.S. Weight Loss Market Worth $66 Billion.” December 20, 2017. www.prnewswire.com/news-releases/us-weight-loss-market-worth-66-billion-300573968.html.
Semedo, Daniela. “In Morbidly Obese, New Non-Surgical Approach May Be an Option.” Obesity News Today. December 7, 2015. www.obesitynewstoday.com/2015/12/07/morbidly-obese-new-non-surgical-approach-may-option.
Shayani, V. “Gastric Balloon — 14 Ways It Will Affect You.” Bariatric Surgery Source. Last updated May 24, 2018. Accessed June 11, 2018. www.bariatric-surgery-source.com/gastric-balloon.html.
Weiss, Clifford R. et al. “Clinical Safety of Bariatric Arterial Embolization: Preliminary Results of the BEAT Obesity Trial.” Radiology 283, no. 2 (May 2017): 598–608. https://doi.org/10.1148/radiol.2016160914.

Notes

1. Susanne A. Fogger and Teena M. McGuinness, “The Relationship Between Addictions and Bariatric Surgery for Nurses in Recovery,” Perspectives in Psychiatric Care 48, no. 1 (February 18, 2011): 10–15, https://doi.org/10.1111/j.1744-6163.2010.00298.x.
2. Jules R. Altfas, “Prevalence of Attention Deficit/Hyperactivity Disorder among Adults in Obesity Treatment,” BMC Psychiatry 2 (September 13, 2002): 9, https://doi.org/10.1186/1471-244X-2-9.
3. Susanne A. Fogger and Tenna M. McGuiness, “The Relationship Between Addictions and Bariatric Surgery for Nurses in Recovery.”