July - Sept 2015: Ask an Expert, Obesity

Q: I’ve lymphedema in my arm since I had treatment for breast cancer 3 years go. I went to a certified lymphedema therapist and wear my sleeve and glove every day. The lymphedema improved, but my arm is still swollen. I’ve gained weight and my therapist thinks that is making it worse. Does weight gain affect my lymphedema?

A: There is quite a bit of evidence that being overweight prior to treatment for breast cancer or gaining weight afterward increases the risk of developing lymph-edema after breast cancer treatment. The good news is that studies have also indicated that if you do develop lymph-edema, losing weight can improve the swelling more than you might expect. Studies of weight loss in individuals with breast cancer-related lymphedema have shown that even modest weight loss, for instance between 7 and 12 pounds, led to significant improvement in arm swelling. And you can also add regular exercise to enhance your weight loss regimen, since studies also show that if exercise (including arm exercise) is performed properly, it does not seem to increase the risk of getting lymphedema or make pre-existing lymphedema worse. In fact, for some patients who have had treatment for breast cancer, upper body exercise may diminish symptoms of lymphedema or even reduce the risk of developing lymphedema in the first place. So add a weight loss regimen and regular exercise to your lymphedema management routine and you may see further improvement.

Q: I have always had big legs, but over the years they have continued to get bigger, and I have pain in my thighs and legs a lot of the time. One doctor told me I have lymphedema, but my therapist thinks I have lipedema. What is the difference?

A: Lipedema is a disorder of fat tissue that affects women almost exclusively and often runs in families. It is usually characterized by excessive deposition of fatty tissue from the waist to the knees or ankles with no swelling in the feet. Although the disorder can vary in the way it presents, women with lipedema usually have disproportionately large hips, buttocks, and thighs, compared to their upper bodies  Usually the soft tissue enlargement is symmetric— that is, the size is similar on both sides. The disorder is also characterized by pain and tenderness in the affected areas and easy bruising. Some people have a mild form of the disorder with modest localized enlargement of the hips, thighs, and/or legs, while others have severe fatty enlargement of the lower body. The disorder sometimes affects the arms as well as the legs.

Over time the lymphatics in the abnormal fatty tissue may also become dysfunctional in persons with lipedema, especially if added obesity is present. In these cases, people with lipedema can develop superimposed lymphedema, which causes fluid to build up in the tissues with additional swelling, pitting, firmness, and other skin and tissue changes not seen in pure lipedema. This combination disorder is referred to as “lipolymphedema.” 

Unfortunately, the lipedema fat tissue tends to be resistant to calorie restriction and weight loss diets. It is nevertheless very important to practice healthy weight management since additional weight gain may result in typical obesity in addition to the lipedema, making the condition worse. Regular intensive exercise may also help prevent worsening of lipedema. Manual lymphatic drainage (MLD) techniques and use of light elastic compression garments may help reduce swelling and painful symptoms. Lipedema may also respond to specialized liposuction techniques to reduce excessive fatty tissue and help relieve pain. If lipolymphedema has developed, complete decongestive therapy (CDT) is usually indicated, including MLD, compression bandaging, and long term use of compression garments. 

Q: After seeing a lot of doctors, I was finally diagnosed with lymphedema in my legs. All the blood tests, vein tests, and scan were normal. I never had treatment for cancer, and no one in my family had lymphedema. The only health problem I have is obesity. Can this cause lymphedema?

A: It seems certain that obesity itself can cause lymphedema, although the exact mechanism is not entirely clear. It is also unclear why some people with obesity get lymphedema and others don’t. Based on available research, it seems likely that inflammation plays an important part in the development of obesity-related lymphedema. Fat tissue produces many metabolically active substances, including hormones and molecules (adipokines), that produce inflammation, damage lymphatic vessels, and diminish lymphatic vessel contractility, which can eventually lead to lymphedema in susceptible individuals. In addition, pressure from large, heavy fatty deposits and associated folds of skin and tissue may obstruct lymphatics and impede lymphatic drainage. Lastly, obesity often reduces mobility and the ability to exercise, which decreases the beneficial effect of the “muscle pump” on lymphatic function. There are likely other physiological and genetic factors in certain obese individuals that may predispose them to developing lymphedema.   

Certainly we know that obesity is a leading cause of lymphedema in the US today, and that obesity also increases the risk of lymphedema in persons who have had treatment for cancer. In addition, obesity can impede effective lymphedema treatment and reduce the beneficial effects of elastic compression garments. So in addition to seeking effective lymphedema treatment (CDT) and managing your lymphedema with compression garments, skin care, and exercise, it is absolutely essential  to incorporate intensive treatment for obesity into your lymphedema
treatment regimen.