Does lymphedema cause weight gain? New study says poor lymphatic drainage promotes fat storage.

By: Ryan Davey, PhD
May 2, 2020
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT

It has been known for a while that obesity can cause lymphedema, but is the inverse also true? Does lymphedema cause weight gain by encouraging the body to store fat? And what would that mean for prevention and management?

The gradual accumulation of excess fluid in a lymphedematous limb will, not surprisingly, gradually increase overall body weight. Conversely, better management of lymphedema will reduce swelling and decrease body weight. But what I want to talk about here is body fat. Clinical studies have long hinted at a complex relationship between lymphatic drainage and adipose tissue (fat deposits) but deconstructing this relationship has been difficult.

Fat is far more than just a place to store excess food energy

Adipose tissue is popularly imagined as inert blobs of lard: stashes of extra food energy collected from our diets for the purpose of fending off starvation or providing insulation against the cold. But the truth is that fat is a remarkably complex and active tissue. Adipose tissue is highly vascularized with blood and lymphatic vessels, and it produces and secretes a variety of hormones involved in energy metabolism and other bodily functions.

In other words, adipose tissue plays numerous important roles in daily life. However, when adipose tissue accumulates to high levels, such as in obesity, its architecture and behaviour poses unique challenges for the lymphatic system.

Excess adipose tissue exacerbates lymphedema and can initiate its onset

The fact that morbid obesity can induce irreversible lymphedema in otherwise normal individuals exposes a design flaw in human anatomy: while our bodies have a fantastical capacity to make and store fat, our vascular architecture is much more limited in its ability to handle the demands excess adipose tissue places on it.

The more fluid-rich adipose tissue you have, the more work your lymphatic system must do to drain the excess fluid (“interstitial fluid”) that is normally left behind by veins and collected by the lymphatic system. The lymphatic system must clear this fluid in order to maintain normal fluid levels and prevent swelling and lymph stagnation. But the lymphatic system has an upper limit on how much fluid it can handle.

Under normal conditions in healthy individuals the lymphatic system operates well below its functional capacity. This leaves a reserve capacity or “gas in the tank” that enables the lymphatic system to handle the exceptional fluid processing demands caused by a broken ankle, pregnancy, or some other swelling-inducing event.

The reserve capacity of the lymphatic system is on display in an obese individual. Despite what might be an enormous increase in body mass and resulting interstitial fluid, the lymphatic system can continue to maintain fluid balance – but only up to a point. At critically high levels of adipose tissue (BMI over 30 kg/m2), it is believed that the lymphatic system can become overloaded by a combination of excess fluid, physically compressed lymphatic vessels, and inflammation. These changes eventually culminate in obesity-induced lymphedema and irreversible damage to the lymphatic system.

But the relationship between lymphatic drainage and adipose tissue is also a two-way street. Not only can dangerously high levels of adipose tissue promote lymphedema, advanced lymphedema promotes abnormal adipose tissue development.

Late stage lymphedema will cause adipose tissue to accumulate in the affected limb

Unmanaged lymphedema is progressive, meaning that it will continue to worsen with time. Chronic swelling leads to further damage and greater swelling and inflammation. It also leads to tissue hardening caused by fibrosis (scarring) and the accumulation of new tissue, especially adipose tissue, which appears to be the result of abnormal stem cell behaviour. One study reported a 73% increase in adipose tissue in patients’ lymphedematous arms compared to their normal arms (ref 1).

So not only can advanced obesity cause lymphedema, advanced lymphedema can case fat to develop in the affected limb.

But does reduced lymphatic drainage encourage the body to store fat?

Advanced cases of lymphedema can cause considerable fibrosis and localized deposition of adipose tissue. But what about less advanced cases of lymphedema, or in people lymphatic drainage deficiencies but no noticeable swelling? Could changes in lymphatic drainage change the way the body metabolizes fat? A fascinating new study published in the International Journal of Obesity suggests that the answer to this question is “yes” (ref 2).

The researchers investigated two groups of premenopausal women with similar levels of body fat: a group with “normal” lymphatic drainage activity in their lower body (as assessed by lymphoscintigraphy) and a group with “worsened” lymphatic drainage activity. For the purposes of this study researchers excluded participants who had potentially confounding conditions such as venous insufficiency, cardiovascular disease, diabetes, cancer, metabolic disorders, obesity, and others. The women who displayed “worsened” lymphatic drainage also did not display overt signs of lymphedema and the volume of their lower limbs were the same as that of their “normal” peers. We can therefore say with good certainty that women with late stage lymphedema were not included in this study, and neither were women with lipedema.

The researches took these two groups of women and looked at how adipose tissue in their upper leg behaved when at rest and when stimulated with adrenaline, a hormone that encourages fat to break down to release energy. They found that women who had worsened lymphatic drainage displayed a lower “in vivo lipolytic index” as well as reduced “lipolytic responsiveness”. In other words, women who displayed worsened lymphatic drainage in their legs had fat stores that were less willing to break down and release energy both when at rest and in response to stimulation.

So does lymphedema cause weight gain by promoting fat? The unwillingness of adipose tissue to release stored energy is likely to be a good predictor of long-term weight gain in women (ref 3). Accordingly, the authors of this study hypothesized that reduced lymphatic drainage in the lower body could make fat deposits in the lower body more resistant to intentional weight loss.

What does this mean for lymphedema management?

This research suggests that even before overt swelling is present, diminished lymphatic drainage is causing changes in the interstitial fluid that bathes cells. These microenvironmental changes convince adipose cells to resist calls to break down fat deposits to release stored food energy.

While this may be the first report of fat metabolism being slowed by reduced lymphatic drainage, this finding is not without precedent. Patients with lipedema develop large and abnormal fat deposits in the lower body, and this process also appears to involve defective microcirculation. There is also evidence that mechanical massage (Endermologie ®) can increase the willingness of adipose tissue in the upper leg to breakdown fats, presumably by improving local microcirculation (ref 4).

We have already known that adipose tissue carries with it a high fluid burden, and at higher levels of adiposity inflammation and mechanical distortion of lymphatic vessels can occur. This has always provided good motivation for individuals with lymphedema to manage their body weight (lest they exacerbate their symptoms), and for obese individuals to work to reduce theirs (among other health reasons).

Now these new findings tell us something more. They suggest that even without overt swelling being present, weakened lymphatic drainage can cause subtle tissue changes that encourage the unnecessary storage of fat. For individuals with lymphedema, awareness of this cycle of lymphatic deficiency promoting fat, and vice versa, should reinforce the urgency with which they approach reducing uncontrolled swelling, and the necessity of good ongoing lymphedema management practices including regular self-massage.

So does lymphedema cause weight gain? Yes, in three ways: (1) uncontrolled lymphedema causes the accumulation of excess fluid, (2) advanced lymphedema (Stage II / II) causes abnormal fat to develop in the affected limb, and (3) weakened lymphatic drainage in otherwise healthy limbs encourages local adipose tissue to resist calls to breakdown fat.

References

  1. Brorson H., Ohlin K., et al. Breast cancer-related chronic arm lymphedema is associated with excess adipose and muscle tissue. Lymphat Res Biol. 2009; 7(1):3-10. abstract
  2. Valaliova Z., Vlasak R., et al. Lymphatic drainage affects lipolytic activity of femoral adipose tissue in women. Int J Obes (Lond). 2020 Mar 5. [Epub ahead of print] abstract
  3. Arner P., Andersson D.P., et al. Weight gain and impaired glucose metabolism in women are predicted by inefficient subcutaneous fat cell lipolysis. Cell Metab. 2018 Jul3;28(1):45–54 e3. abstract
  4. Marques MA, Combes M, Roussel B, Vidal-Dupont L, Thalamas C, Lafontan M, et al. Impact of a mechanical massage on gene expression profile and lipid mobilization in female gluteofemoral adipose tissue. Obes Facts. 2011;4(2):121–9. abstract

Comments

  1. Ada Moore Ada Moore says:

    Would love to talk to someone regarding this article on lymphedema. It appears that my sister has this and no one around us seems to know what it is.
    Ada

  2. Mrs Angela Behennah Mrs Angela Behennah says:

    This is very interesting. I had surgery for breast cancer in March 2019. I had a sentinol lymph node removed which was negative. I then had radiotherapy and was put on Tamoxifen with horrendous effect. I was taken off the drug after 12 weeks as one of the symptoms was that I had put on 12Kg of weight. Now, 3 years on, I still cannot shift the weight. I have been told it is not Lymphodema, but no-one knows how to help me. I am convinced it is down to the lymph node being removed. I had never had a weight problem before and I am completely desperate for help. I have seen 13 doctors and no-one knows what to do. They agree it is down to the surgery, but don’t know how to help me.

    • Hello Angela,

      Thank you for sharing your story with our readers. I am very sorry to hear of such a challenging time you had with the Tamoxifen. May I ask, did they transition you to another aromatase inhibitor, in place of the Tamoxifen? Estrogen-suppressive medication can certainly cause women to gain weight following breast cancer treatment, and in fact, more than half of breast cancer patients do gain weight throughout the course of treatment. The hormonal effects of estrogen suppression and menopause is certainly I would suggest you speak to your medical oncologist about, though I am sure you have done so already by the sounds of your comments. Lymphedema would only affect the arm, trunk, and/or breast on the affected side, and while this does add to a weight increase on the scale, if your team members do not feel you have lymphedema/swelling per se, and the weight gain affects your whole body evenly, then it is much more likely to be due to the medications you’re on, or naturally occurring menopause, or other treatment-related effects. I am so sorry that you’ve seen so many experts and that nobody has a solution to offer you. If you are in a city where you could meet with a CDT therapist, they could readily determine whether it is lymphedema or not, if there is still a question mark related to this possible contributing factor. Lymphedema has to be quite advanced to cause weight gain as described in this article, so if your team is not convinced you have lympmhedema, and since it would only affect your one arm/trunk/breast, it is unlikely the isolated cause of your significant weight gain.
      Best of luck in your on-going search for additional support Angela, you are certainly not alone in your experiencing of weight gain following breast cancer treatment, that much I can attest to.
      Best wishes,
      Lindsay Davey

  3. Ann Cowern Ann Cowern says:

    Loved this article. I have a problem. I need to lose weight. My weight has been stable for 20 years but over weight. Nothing I try helps. I have a underactive thyroid, does this affect !the lymph system? My excess weight seems like fluid especially in abdominal region. I am 72 years old.

    • Hello Ann,
      Thank you for your comment. I’m glad your weight has been stable, though I know frustrating if it is higher than you’d like it to be. An underactive thyroid condition is not known to be specifically linked to any concurrent issue in terms of the lymphatic system, no. An abdominal-focused fluid accumulation would be somewhat more atypical for a classic lipedema or lymphedema presentation, which tend to present with limb-based swelling primarily speaking.
      All the best in your weight loss goals and symptom management Ann. I hope at least the underactive thyroid is being managed effectively by your physician team members. Best, Lindsay Davey

  4. Joe Rubin Joe Rubin says:

    This study is welcomed and fascinating. But as is typical, I find no reference to men with post surgical lymphedema referenced. Following a prostatectomy and removal of a few lymph nodes over four years ago, I was diagnosed with lymphedema, primarily in my left leg. I had previously enjoyed a high level of fitness, but having gained almost 20% more weight I struggle to do anything more than daily routines. No amount of exercise or diet management seems to help; I have suspected some metabolic change and fluid retention. While my leg is managed quite well with a compression pump and garment, my trunk carries much more bulk than ever in my 71 years.

    • Hello Joe,

      Thank you for these comments and for sharing your own story of weight gain related to your prostatectomy. Indeed, more studies are needed on the post-prostatectomy experience of lymphedema, which is not discussed enough in the literature, and often not enough in the surgeon’s and radiation oncologists’s office either, from what our patients tell us. I’m pleased to hear you have managed the leg lymphedema as well as you have with the pump and garment use. Many of our prostate cancer patients are on hormone-modifying drug therapy for a period of time following their surgery/radiation therapy course, which can also certainly contribute to weight gain (particularly in the trunk/midsection they find). Alteration in hormone levels (specifically post prostatectomy, the androgen-blocking agents) are known to cause weight gain so if you are taking a medication such as this, this too could contribute to the weight gain you’re experiencing, which would indeed be much more resistant to weight loss strategies such as exercise and dietary changes). I always encourage our patients to discuss this with their medical oncologists so that their changes in weight is monitored, and so that any other co-morbidities can be addressed that may develop on account of the (typically truncal) weight gain. I hope this provides another perspective for you Joe, and that you might enjoy a higher level of fitness at some point in the future, perhaps with the support of a dietician or exercise professional/team who are experienced in tailoring a weight-loss programs for those with your history and reason for the weight gain. My best wishes to you, Lindsay Davey

  5. Susie Savino Susie Savino says:

    Thank you for this article. I had breast cancer in my left breast stage 3B estrogen receptive Her2positive in 2003. I believe I had 30 lymph nodes removed with 23 cancerous. I was barely 40. I was in good health, worked our had a BMI of 20.9. I was warned about lymphedema and even had several massages early on. I had a garment that was a terrible fit so I never used it. I didn’t have any trouble at all for about five years. They put me on Femara since my treatment put me into early menopause! 3 years after I started having periods like clockwork. Dr.s forced menopause with different medications but as soon as they stopped I would come out of it. After the 3rd time I refused all medication including the Famara since I found it was only 17 % more effective than Tamoxifen and also finding that Tamoxifen wasn’t very effective so that’s not saying much. In the beginning I had only slight problems and was able to get lymphedema under control with messages both from PTs and self messages. In 2017 it became really bad after an allergic reaction to some essential oils. Since that time it has been very difficult to manage. I’ve consistently worked on my weight and was able to keep it somewhat under control until 2019 when I had a lymph node transfer done from my groin to just below my elbow. Lymph nodes were then connected to blood vessels there. I also had two lymph nodes connected to blood vessels at my wrist. The surgery did not improve anything. I was told it might not work but there was only 2% chance it could be made worse! It is worse not to much more but it is worse. The main thing though is my weight gain. Since that surgery I’ve gained almost 25 lbs and I seem to continue to gain. I’ve been trying everything, Liver cleanse, exercise, restricting calories, but I continue to slowly gain. Im convinced it has to do with my lymph system! One of the things they were supposed to do after I was healed up from the lymph surgery was to get liposuction in my arm. I don’t really trust that not to cause more problems with my lymphedema so I have declined. 

    • Hello Susie,
      Thank you for relaying your personal journey here, I’m sure it will be very informative to others who may be considering pursuing lymph node transfer surgery and who have had a similar history. I am personally not as familiar with LNT procedures in my own patient caseload as this surgical option is not readily available here in Canada, but I do hope that further research and trials can continue to inform us about the best candidates for this procedure and how best to optimize recovery/outcomes in those that pursue it. I’m very sorry to hear of the challenge you’ve had with your weight gain which does indeed confound lymphedema, as you have found. Know that you are not alone and my best advice is to continue with your healthy eating and exercise routines so as to mitigate the weight aspect, and I do hope that your team can continue to support you in your lymphedema management. possibly with new ideas in terms of massage, compression options, exercise options, and other strategies to help manage it over the long-term. Wishing you my best wishes Susie, and thank you again for sharing your story. Lindsay Davey

  6. Mary Ker Mary Ker says:

    I’ve read your articles here and your responses with great interest. I have begun the journey of vasar plastic surgery From a specialist in Pasadena. My lipidemia was quite advanced. None of my doctors would deal with it. My primary doctor said he had never heard of it and would have to look it up. They said I was simply overweight and got to a point where I could almost not walk. They recommended a gastric bypass and I would not do it.  This Out of network surgeon removed 12 L of fluid from my left lower leg only 2+ weeks ago. It’s very slow going. It’s very painful. I have a lot of surgeries ahead of me. I have a keen interest in everything you have written and Look forward to more doctors being aware of this condition. I never thought I was fat maybe 8K overweight at the onset now I look around me and Sometimes see women with tiny feet and ankles, but legs that are blowing up and I know right away what the problem is, but Doctors just don’t seem to address it. Thank you for the information you shared. I’m looking forward to a better life through vasar liposuction But of course, no insurance covers it and I am scraping together to get the help I must have.
    Thank you for your research and sharing your findings.

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