The Covid 19 pandemic with its lockdowns, reduced ability to exercise and comfort eating, will have inevitably led to some weight gain across the nation.
However long before the emergence of Covid-19, obesity was rapidly becoming a national epidemic, with estimates of 50% of the UK’s adult population being obese by 2030 (Lancet 2011).
We know that large increases in body weight can potentially lead to a variety of illnesses such as diabetes, venous disease, joint problems, heart disease, as well as chronic oedema and the development and deterioration of lymphoedema.
There is, perhaps more worryingly, an increase in childhood and adolescent obesity, which is storing problems for our future generations.
It is becoming clear that fat cells influence our lymphatic system and its ability to function normally
What we eat in our ‘normal’ diet and how it may affect the development of lymphoedema is unclear. However, we do know that some primary lymphoedema patients experience symptoms similar to Irritable Bowel Syndrome (IBS) due to abnormal gut lymphatics. Changing the type of fat in the diet of these patients can significantly reduce these symptoms and in some cases, improve the severity of their lymphoedema.
It is well recognised that obesity is associated with the development of secondary lower limb lymphoedema, especially in patients who already have chronic venous insufficiency (CVI), which is also often initiated by a high Body Mass Index (BMI). (BMI is a recognised measurement tool that uses body weight and height to determine if we are overweight and to what degree.)
In 2012 a study of 15 patients with a BMI of 30+, swollen lower legs, but no other cause for the swelling, were examined using lymphoscintigraphy, (a specialised scan of lymphatic vessels). The results showed 5 of them had abnormal lymphatic function; all these patients had a BMI of 59+. (Green et al, N Engl J Med 2012;366:2136-2137).
These results suggest, as weight increases, there may be a threshold at which our lymphatic flow reduces. This may be due to compression, obstruction, or inflammation of vessels, causing them to function less effectively.
Theoretically, this may then exacerbate primary or secondary lymphoedema.
It may also explain why, once weight starts to reduce, the lymphatics may, to some extent, improve again and oedema reduces.
Several of my patients now have much more manageable limbs purely due to weight loss
Common sense should tell us that carrying excess body weight will put strain on the heart, lymphatic, and venous systems which we rely on to pump, transport, and drain tissue fluid, thus preventing us developing oedema. In addition, venous disease, direct pressure on lymphatic vessels from fatty tissue, positional obstruction of drainage vessels in the groin by a large abdomen, and inability to elevate heavy legs, all exacerbate the situation. Other systems then become affected – knees and hips suffer from the strain of carrying excess weight, which in turn leads to reduced mobility and calf pump action (“heel-toe” walking gait) – one of the keys to reducing oedema.
It is not just lower limbs that are affected; studies in 2008 from the University of Missouri, Columbia (Journal of Lymphoedema Vol3 No2) suggest there is an increased risk of 40-60% of developing lymphoedema after breast cancer surgery in women with a high BMI.
The problem does not stop with obesity influencing how lymphoedema develops, it also restricts how it can be managed and treated. It is much more difficult for therapists to treat obesepatients. Apart from the obvious physical injury risks associated with the manual handling of heavy limbs, there may be other safety limitations. Specialist equipment such as wider and higher weight bearing bariatric couches may not be available, along with access to appropriate toilet facilities, physical access to treatment rooms (e.g., bariatric wheelchairs do not fit through standard doorways) and adequate space to safely treat patients.
All this may require extra resources, not readily available in the current financial climate, especially for small clinics or independent therapists. Treatment may then have to be delayed until the patient has shown a decrease in weight.
To protect therapists from injury due to lifting heavy limbs, one clinic in Scotland has recently introduced a traffic light scheme of allocating work to therapists. This ensures they have an even daily allocation of patients and limit the number of obese patients seen each day. If your therapist injures their back from repetitive lifting of a heavy limb, they could be off work for several weeks, which in turn will delay your treatment and that of others.
Treatment generally is less effective, and the overall course of treatment takes longer when dealing with fatty tissue. Regardless of how experienced the therapist is, bandages tend to slip/crease easily. This has a knock-on effect with the length of treatment time required, which may then build up a waiting list for the clinic, delaying treatment availability.
Hosiery is also much more expensive and difficult to fit correctly, which may prove to be a financial problem for some services on limited budgets and restrict what is available. Although many garments are supplied on prescription, there are, at times, issues with obtaining expensive garments.
As therapists, we know from experience that when patients reduce weight significantly, there is a direct improvement in oedema – in both upper and lower limbs.
We do, however, appreciate how difficult weight management can be, but we also know that any treatment options are really hampered unless weight and BMI are within reasonable limits. Your therapist will guide and support you to a certain degree to reduce weight and various schemes to help are available through GP referral now such as prescribed access to ‘Weight Watchers’, ‘Slimming World,’ dietetic advice, and possible referral to a specialist Bariatric Team. However, ultimately the only person who can lose weight, is the person themself, and unless that happens, your therapist may be extremely limited in how far they can improve your condition.
There are success stories, and several of my patients now have much more manageable limbs purely due to weight loss. For treatment to be successful though, there must be a committed partnership between therapist and patient.
About the author
With a background in vascular surgery & District nursing, chronic oedema & lymphology have been the focus of Sue’s nursing career for the past 30 years. Since 1997 Sue has developed and managed the Lymphoedema service for Mid & North Bucks based at Florence Nightingale Hospice, Aylesbury. The service is nurse led & treats Primary & Secondary Lymphoedema along with an increasing caseload of chronic oedemas.