In the United States, anywhere from .5–3.7 percent of all females will meet the diagnostic criteria for anorexia at some point in their lives. About 1–4 percent of all females will struggle with bulimia.1 The people who are most prone to anorexia and bulimia tend to be adolescent girls and young women. At the opposite end of the scale, 64 percent of all mature adults—both men and women—are overweight or obese.2 With these astonishing and often contradictory statistics, it is easy to draw the conclusion that as a culture we Americans have a less-than-optimally functional relationship with food. Nowhere is this better illustrated than in the headlines we see every day in supermarket checkout lines: a new diet, a new dessert recipe, all on one explosive page.
In this edition of Massage & Bodywork dedicated to honoring the body, we will examine some of the health and pathology issues related to chronic over- and under-eating, with special emphasis on the role massage can play as our clients live with these challenges. We will address three basic varieties of disordered eating: anorexia, bulimia, and binge eating.
Overview
Many people with eating disorders report that their choices and behaviors around eating are less about food and more about a chance to enact a sense of personal control in a world where they can feel profoundly powerless. Ironically, dysfunctional eating habits can quickly become ingrained and that sense of control can be completely overwhelmed by addictive and self-destructive behaviors.
It isn’t hard to point to the media as a source of misinformation about what healthy bodies “should” look like. [A wonderful example of this is available at www.youtube.com/watch?v=tbb8D-u8ues.]
The influence of television, billboards, magazine ads, and the fashion industry is obviously a factor for many people, but while all of us are exposed to the media, not all of us develop eating disorders. Other factors, like concurrent anxiety disorders (especially obsessive-compulsive disorder), depression, self-esteem issues, family culture, and peer pressure can all play into this scenario. Further, it seems clear that some internal triggers and chemistry may also be involved. Studies of the neurotransmitters of some people with eating disorders reveal some differences in serotonin secretion: this opens some doors to additional treatment options that may assist in a successful recovery process.
Anorexia Nervosa
Although classified as an eating disorder, anorexia is not a digestive system issue: it is a psychological problem. It is a condition in which a person essentially starves herself through drastically limiting caloric consumption (restrictive anorexia) or by consuming barely enough for sustenance and then overcompensating through purging or exercise (purge-type anorexia).
The stereotypical anorexia patient is a teenager or young woman, often an overachiever with unrealistically high expectations of herself. Patients are frequently involved in activities that place a high value on small size, like gymnastics, skating, or dance. Men and boys can also develop anorexia (this is especially common among athletes who work with weight restrictions, like wrestlers and jockeys), but males comprise only about 10 percent of all diagnoses.3
An anorexic patient typically doesn’t view herself as underweight. On the contrary, many patients show a highly distorted sense of their own size, viewing themselves as obese, when in fact they may be dangerously thin. One of the features of anorexia that can make it hard to identify early is that aspects of this disease contribute to hiding its results. Anorexic people carefully avoid situations where they might be seen eating (or rather, not eating), and they often dress in heavy, baggy clothing—this is both because they are frequently cold and because they feel this hides their unsightly mass.
Bulimia Nervosa
Bulimia (literally, “ox eating”) is a condition in which a person drastically overeats (binges) and then compensates through inducing vomiting or excessive exercise. Many people go back and forth between bulimic and anorexic behaviors; the main difference is that bulimics take in enough calories to maintain normal weight. This doesn’t mean bulimia is less dangerous than anorexia; compensation activities can have long-lasting and dangerous complications.
Binge Eating
Binge eating is a situation that has only recently been recognized as a pathologic condition. This label describes a person who goes through frequent bouts of frenzied overeating: episodes leave him or her feeling sick and distressed and are permeated with a sense of loss of control. Binge eating disorder is unique in that its incidence in men is much higher than either anorexia or bulimia: up to 35 percent of people with binge eating disorder are males.4
Complications of Eating Disorders
Eating disorders can quickly become life-threatening problems. If circumstances are just right, our bodies have a remarkable, even alarming, ability to adapt to new habits even though they may be self-destructive. British journalist Kate Spicer undertook to lose enough weight in six weeks to fit into size zero jeans for the film documentary Super Skinny Me. She started the experiment, in her words, “nicely fit, but a wee bit porky at a little over 10 stone” (about 140 pounds). In the process, she describes the feeling of constant hunger, wooziness, and a strange fascination: “The truth is, the more weight I lose, the fatter I feel and the more I want to lose weight. I lie in bed in the mornings feeling my hipbones and wanting to feel them more. I want them to jut out.”
When Spicer reported to her doctor that she had used a laxative to keep to her diet, she was instructed to stop the experiment and to begin eating normally. This was her response (emphasis mine): “Eating normally? Forget it. My mind is not my own anymore. Under stress, when I need to write, I often eat. It’s not cool, I don’t like it, but I do. I am terrified and confused. My body is hungry, but I am continuing to try and control my eating. The consequence of this is binging. I binge and then stick my fingers down my throat. All I want is to be thin.”5
Losing control of eating patterns is only one complication of eating disorders. Several others exist as well.
• Osteopenia. One consequence of being underweight is the cessation of the menstrual cycle—it is essentially the early onset of menopause, with the shift in calcium metabolism that accompanies it. Because many anorexia and bulimia patients are young women, this means they are losing bone density (osteopenia) at exactly the time of life that it should be rapidly accumulating. The consequences of this are an early onset of osteoporosis that may be difficult or impossible to reverse.
• Esophageal damage. Inducing vomiting introduces gastric secretions to the esophagus much more frequently than it can tolerate. Consequently scarring, strictures, or ulcers may form. In worst-case scenarios, the esophagus can even rupture.
• Dental damage. Chronic exposure to hydrochloric acid can remove the enamel from the teeth. Eroded molars are one of the signs of self-induced purging.
• Electrolyte imbalance; arrhythmia. Frequent vomiting or diarrhea brought about by laxative use can interfere with healthy electrolytes and fluid management. One consequence is an irregular heart rhythm due to potassium disruption.
• Colon dysfunction. Even though using laxatives doesn’t interfere with caloric uptake (that happens in the small intestine), people with eating disorders often use these substances to clear themselves out. But the colon can become dependent on these artificial stimulants and may not be able to function normally when usage is stopped.
• Death. People with eating disorders are vulnerable to heart problems, massive infections, and the extreme dehydration that accompanies purging. Their baseline health is typically precarious, so any extra stressor or challenge can completely overwhelm their system.
Binge eating disorder and chronic overeating leading to overweight and obesity also carry important consequences, but fortunately these tend to have a slower onset and can be more reversible or manageable than those seen with anorexia and bulimia.
• Cardiovascular disease. As the leading cause of death in the United States, atherosclerosis and the risk of heart attack cannot be dismissed as a trivial consequence of overeating. However, much of the damage related to cardiovascular disease can be avoided or reversed if eating and exercise habits are changed.
• Fatty liver disease. Chronic liver damage related to high-fat diets is now being identified as a factor in the development of cirrhosis and liver failure—conditions that were recently associated mainly with alcoholism, drug abuse, or hepatitis infections.
• Type 2 diabetes. Responsible for about 10 percent of all healthcare costs, the leading cause of new blindness in people under 70 years old, and the number one reason for kidney transplants, type 2 diabetes is directly related to wear and tear on both the pancreas through high-sugar diets and on insulin receptor sites, especially on skeletal muscle cells.
• Osteoarthritis. This condition, which involves the destruction of articular cartilage, is a particular risk for overweight people who can be crippled by pain in hips or knees. Joint pain leads to another vicious circle: if it hurts to be active, then it’s difficult to lose weight; accumulating weight puts more pressure on joints, which makes it hurt to be active.
Eating Disorders and Massage
It is interesting that the diagnostic criteria for eating disorders do not include any reference to people who habitually eat for reasons other than hunger or who habitually eat food that does not support them—both habits that strongly contribute to our country’s rate of obesity. From the perspective of a bodywork practitioner, it would be interesting to examine the relationships between touch deprivation and eating habits. The United States is a relatively low-touch culture, and we place a high premium on the desirability of slenderness. If we consider that touch is a primal human need, and if we look at the lining of the gastrointestinal tract (running in a continuous tube from mouth to anus) as simply an internal version of our external skin, it is easy to see the act of overeating as the delivery of a snug, fulfilling, inside-out hug in a setting where positive human skin contact may be rare. Further, as found in the Touch Research Institute study of massage and anorexia, many patients with anorexia express a sense of touch deprivation, and experience a very positive reaction to the nurturance they receive with massage.6
Risks of massage for clients with eating disorders depend mainly on what kind of complications they have developed. It seems odd to think of osteoporosis as a challenge for young women, but this may be in the picture for extreme anorexia. A person who has difficulty regulating electrolytes because of frequent purging may have problems with irregularity of her heart beat. These and other complications are issues that need to be discussed with clients’ primary healthcare providers.
Given the prevalence of dysfunctional eating patterns in the United States, it is safe to predict that most massage therapists have clients who live with eating disorders. It is also safe to suggest that hundreds of thousands—maybe millions—of people would love to receive massage, but avoid it out of a sense that because of their size they don’t deserve it, or they fear being judged, as seen in this blog entry: “I would love a massage. I’ve never actually had one, but I hear they’re great. I would just never have my shirt off in front of anyone, in any context. Keeps me out of doctors’ offices, massage studios, and off beaches.”7
As massage therapists, we have a wonderful opportunity to introduce positive, educated, nonjudgmental touch into the lives of people—fat, thin, and in-between—who don’t experience their bodies as a good place to be. When our clients keep an appointment, they give us a delicate and precious gift: the trust that we will meet them with love and compassion where they are, as they are. Let us accept that gift and return it with all the reverence that our clients deserve.
Ruth Werner is a writer and educator who teaches several courses at the Myotherapy College of Utah and is approved by the NCBTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.
Notes
1. “Eating Disorders: Facts About Eating Disorders and the Search for Solutions,” National Institute of Mental Health, NIH Publication No. 01-4901. Available at www.nimh.nih.gov/Publicat/eatingdisorders.cfm (accessed winter 2009).
2. Obesity Statistics, NAASO, The Obesity Society, 2006, www.naaso.org/statistics/obesity_trends.asp (accessed Winter 2009).
3. Ruth Werner, A Massage Therapist’s Guide to Pathology, fourth edition (Lippincott Williams & Wilkins, 2009), 277–82.
4. “Eating Disorders: Facts About Eating Disorders and the Search for Solutions.” Ibid.
5. K. Spicer, “My Six-Week Journey to the Land of Thin,” Times Newspapers Ltd., 2008. Available at http://women.timesonline.co.uk/tol/life_and_style/women/diet_and_fitness/article1625715.ece (accessed winter 2009).
6. T. Field, Touch Therapy (Philadelphia: Churchill Livingstone, 2000), 155–61.
7. Fatty McBlog, May 2006. Available at http://fattymcblog.blogspot.com/2006/05/harder-harder-yes-yes-yes-right-there.html (accessed winter 2009).