Lymphedema can develop for many reasons. Much of the information available on lymphedema focuses on cancer treatment-related lymphedema. However, one of the most common causes for lymphedema is actually obesity. Often in combination with venous insufficiency, inflammation, and insulin resistance. Robert Erkstam, OTR, CLT-LANA, and Leslyn Keith, OTD, CLT-LANA explain the connection between obesity and lymphedema.

Obesity & Lymphedema:  What is the Connection?

 

Currently, 39% of the world’s adult population are overweight and 13% are obese (Ritchie & Roser, 2017). Unfortunately, the rates of obesity are even higher in those with lymphedema. The large, multi-country Lymphedema Impact and Prevalence study (LIMPRINT) showed that over half of people diagnosed with lymphedema were also obese (Keast et al., 2019; Keeley et al., 2019). 

 

How are obesity and lymphedema related?

The contribution of obesity to lymphedema is two-fold:  first, from an increased fluid load that pools in gravity-dependent tissues (most often the lower legs and feet) and second, from the reduced ability of the lymphatic system to remove that fluid from the tissues.  Further, if you are at risk for lymphedema due to cancer treatment, you are as much as 3x more likely to develop lymphedema if you are obese (Paskett et al., 2012; Ridner et al., 2011; Ugur et al., 2013).

 

Why is there an increased fluid load in the presence of obesity?

Inflammation – Inflammation by itself is not always bad, as it is part of the immune response when there is an infection, and it is an important stage in wound healing.  One of the by-products of inflammation, however, is increased fluid load and swelling (Reed & Rubin, 2010).  In the presence of obesity, the fat tissue is in a state of chronic low-grade inflammation (Xu et al., 2003), so we can expect that there would be increased fluid in the tissues that would need to be evacuated by the lymphatics.

Venous hypertension – Obesity can cause venous hypertension and insufficiency by mechanically obstructing the flow of blood as it attempts to return to the heart. Slower circulating blood tends to pool in the veins, causing the pressure to go up. This creates a problem for the lymphatics both when trying to keep up with the increased fluid load in the tissues and when attempting to shift the fluid burden from the thoracic duct to the subclavian vein.  If pressures are too high in this vein, the easy transfer and flow of lymphatic fluid is impaired (Paulus et al., 2008).

Leaky blood vessels – The glycocalyx is the lining in blood vessels that controls what goes in and what goes out of them.  When this lining is damaged, the blood vessels become extra leaky which will contribute to increased fluid load and swelling (Ahn et al., 2022).  A high carbohydrate diet, the biggest cause of obesity, is severely damaging to the glycocalyx (Nieuwdorp et al., 2006).

 

How Does Obesity Reduce the Transport Capacity of the Lymphatics?

Leaky lymphatic vessels – Lymphatic vessels can become leaky in the presence of obesity, just like blood vessels. One reason the lymphatics become leaky is that adiponectin, a hormone generated by fat tissue that is vital in lymph vessel wall integrity, is suppressed when there is excessive fat (Shimizu et al., 2013). Insulin resistance and type 2 diabetes, two conditions commonly associated with obesity, can also degrade lymphatic vessels (Scallan et al., 2015) and increase swelling.

Inflamed lymphatic vessels – The lymphatic vessels themselves can become inflamed and swollen when exposed to obesity-inducing diets, resulting in impaired and slowed lymph transport.  In one animal study, rats fed a typical Western high-fructose diet showed significant swelling and narrowing of lymphatic vessels resulting in a 50% reduction in lymph flow (Zawieja et al., 2012).

Mechanical impingement of veins and lymphatics – Excessive fat tissue in the abdomen can drape over the groin, especially in sitting and can obstruct both blood and lymph flow out of the legs and into the trunk (Waldman, 2016).  Excess fat with obesity can also create lymphatic and venous impairment behind the knees and around organs (Lean, 2000). Decreased circulation will inevitably leave more fluid in the tissues and result in swelling.

Decreased mobility – Movement with muscle contraction is a major factor in lymphatic flow.  Increased pain, especially in the knees, is frequently associated with obesity which can mean that activity is severely restricted.  This will negatively impact the muscle and joint pump, reduce lymphatic transport, and ultimately result in more swelling (Negrini & Moriondo, 2011).

 

What can you do about it?

Complete Decongestive Therapy (CDT) – This is a combination of manual lymph drainage (MLD – a specialized massage technique), compression bandaging, skin care, and decongestive exercises that are provided by a trained and certified lymphedema therapist.  This treatment is the gold standard for reducing and controlling lymphedema. 

Compression Garments – Effective and comfortable compression is key.  This can only be achieved by consulting with an experienced lymphedema therapist or fitter.  Good compression will keep the swelling from coming back and will help maintain better circulation.  All of this will contribute to your legs feeling better.

Movement/Exercise – A consistent exercise program will help improve lymphatic drainage to manage swelling with regular use of your muscles and joint pumps.  There are many other physical and mental health benefits as well!  https://ourcorematters.com/101-reasons-to-exercise/

Diet – Reducing carbohydrate intake has been shown to be the most effective method of achieving meaningful weight loss.  A low carbohydrate or ketogenic eating plan has also proven to be effective for better management of lymphedema and lipedema (Keith et al., 2017; Sørlie et al., n.d.).  

 

There is hope!  Learn how to create an Upward Spiral for your health and well-being

As you lose weight, your lymphatic system will function better, and you will feel better.  You will be more inclined to move more, so your physical activity will increase.  You may notice you are sleeping better and have less brain fog.  Learn more about how to transform your life by taking our 12-session lifestyle course for better management of your weight and lymphedema.

https://self-care-therapy.mykajabi.com/Lymphaticlifestylesolutions

 

References

Ahn, S. J., Le Master, E., Lee, J. C., Phillips, S. A., Levitan, I., & Fancher, I. S. (2022). Differential effects of obesity on visceral versus subcutaneous adipose arteries: Role of shear-activated Kir2.1 and alterations to the glycocalyx. American Journal of Physiology Heart and Circulatory Physiology, 322(2), H156–H166. https://doi.org/10.1152/ajpheart.00399.2021

Keast, D. H., Moffatt, C., & Janmohammad, A. (2019). Lymphedema Impact and Prevalence International Study: The Canadian data. Lymphatic Research and Biology, 17(2), 178–186. https://doi.org/10.1089/lrb.2019.0014

Keeley, V., Franks, P., Quéré, I., Mercier, G., Michelini, S., Cestari, M., Borman, P., Hughes, A., Clark, K., Lisle, J., Benson, M., Noerregaard, S., Karlsmark, T., Murray, S., & Moffatt, C. (2019). LIMPRINT in specialist lymphedema services in United Kingdom, France, Italy, and Turkey. Lymphatic Research and Biology, 17(2), 141–146. https://doi.org/10.1089/lrb.2019.0021

Keith, L., Rowsemitt, C., & Richards, L. G. (2017). Lifestyle modification group for lymphedema and obesity results in significant health outcomes. American Journal of Lifestyle Medicine, 155982761774210. https://doi.org/10.1177/1559827617742108

Lean, M. E. J. (2000). Pathophysiology of obesity. Proceedings of the Nutrition Society, 59(3), 331–336. https://doi.org/10.1017/S0029665100000379

Negrini, D., & Moriondo, A. (2011). Lymphatic anatomy and biomechanics. The Journal of Physiology, 589(12), 2927–2934. https://doi.org/10.1113/jphysiol.2011.206672

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Paskett, E. D., Dean, J. A., Oliveri, J. M., & Harrop, J. P. (2012). Cancer-related lymphedema risk factors, diagnosis, treatment, and impact: A review. Journal of Clinical Oncology, 30(30), 3726–3733. https://doi.org/10.1200/JCO.2012.41.8574

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Ridner, S. H., Dietrich, M. S., Stewart, B. R., & Armer, J. M. (2011). Body mass index and breast cancer treatment-related lymphedema. Supportive Care in Cancer, 19(6), 853–857. https://doi.org/10.1007/s00520-011-1089-9

Ritchie, H., & Roser, M. (2017). Obesity. Our World in Data. https://ourworldindata.org/obesity

Scallan, J. P., Hill, M. A., & Davis, M. J. (2015). Lymphatic vascular integrity is disrupted in type 2 diabetes due to impaired nitric oxide signalling. Cardiovascular Research, 107(1), 89–97. https://doi.org/10.1093/cvr/cvv117

Shimizu, Y., Shibata, R., Ishii, M., Ohashi, K., Kambara, T., Uemura, Y., Yuasa, D., Kataoka, Y., Kihara, S., Murohara, T., & Ouchi, N. (2013). Adiponectin‐mediated modulation of lymphatic vessel formation and lymphedema. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, 2(5). https://doi.org/10.1161/JAHA.113.000438

Sørlie, V. et al. (n.d.). Effect of a ketogenic diet on pain and quality of life in patients with lipedema: The LIPODIET pilot study. Obesity Science & Practice, n/a(n/a). https://doi.org/10.1002/osp4.580

Ugur, S., Arıcı, C., Yaprak, M., Mescı, A., Arıcı, G. A., Dolay, K., & Ozmen, V. (2013). Risk factors of breast cancer-related lymphedema. Lymphatic Research and Biology, 11(2), 72–75. https://doi.org/10.1089/lrb.2013.0004

Waldman, R. A. (2016). Dermatologic Manifestations of Obesity: Part I Mechanical Causes. Journal of Obesity and Weight-Loss Medication, 2(1). https://doi.org/10.23937/2572-4010.1510010

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Zawieja, S. D., Wang, W., Wu, X., Nepiyushchikh, Z. V., Zawieja, D. C., & Muthuchamy, M. (2012). Impairments in the intrinsic contractility of mesenteric collecting lymphatics in a rat model of metabolic syndrome. American Journal of Physiology – Heart and Circulatory Physiology, 302(3), H643–H653. https://doi.org/10.1152/ajpheart.00606.2011