Lymphedema caused by obesity may not be reversible
By: Lindsay Davey, MScPT, MSc, CDTMarch 15, 2020
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT
There are many reasons to maintain a healthy body weight, but preventing the chronic swelling condition known as lymphedema is probably one that you’ve never heard of.
In fact, there’s a good chance that your family doctor hasn’t heard of the connection between obesity and lymphedema either. This is not surprising. The link between obesity and lymphedema was discovered only relatively recently, and this type of swelling can be difficult to diagnose in individuals who are obese. When swelling is noticed, venous insufficiency is usually the go-to diagnosis for physicians.
This is a potentially harmful misstep; missing or incorrectly diagnosing lymphedema can lead to worsening of symptoms and potentially permanent health complications – including irreversible lymphedema.
What is lymphedema?
Lymphedema is chronic swelling in an area of the body, usually a limb, caused by a failure of the lymphatic system to adequately remove ‘lymph’ fluid.
The circulatory system delivers oxygen and nutrient rich blood throughout the body. A fluid called ‘plasma’ leaves the blood to deliver nutrients to cells, and to collect cellular waste. Most but not all of this fluid returns to the blood stream and is pumped back to the heart through the veins. The remaining fluid, called ‘lymph’, is collected by lymphatic vessels and ultimately dumped back into the blood stream to rejoin the body’s circulatory system.
The circulatory and lymphatic systems work together to continuously balance fluid levels throughout the body. If the lymphatic system fails to function normally in an area of the body, the circulatory system cannot compensate for the excess fluid, and swelling occurs. When left untreated, lymph fluid accumulation will progress and can cause disfiguring swelling, tissue changes including a hardening of the skin and underlying tissues, susceptibility to infection and skin ulcers, reduced range of motion in the limb, and diminished quality of life.
There is currently no cure for lymphedema, patients with lymphedema must instead manage and monitor their symptoms on an ongoing basis.
Obesity and lymphedema: an underappreciated health hazard
Lymphedema usually occurs as a side effect of cancer and cancer treatment. Tumor growth, surgery, radiation and chemotherapy can all be sources of damage to the lymph vessels and lymph nodes that comprise the lymphatic system. Most people are unaware that the lymphatic system can also be damaged by excess fat deposits.
A link between obesity and lymphedema has long been hypothesized. For example, increased body weight has been shown to increase the risk of lymphedema in breast cancer patients (ref. 2) whose cancer treatment predisposes them to developing it. But the first strong evidence of a connection between obesity and lymphedema in otherwise normal individuals appeared in a 2012 study published in the New England Journal of Medicine (ref. 1).
These researchers found that every participant in their study who had a body-mass-index (BMI) of 59 kg/m² or more (but who were otherwise healthy) presented with insufficient lymphatic flow in the lower extremities – a hallmark of lymphedema.
Table 1: Positive lymphoscintigraphy results indicative of lymphedema appear to arise more commonly in individuals with a BMI of over 59 kg/m2. Adapted from reference 1.
How obese do you need to be before you get lymphedema?
In 2015 the same research group sought to answer this question using a group of patients referred to their center for suspected lower-extremity lymphedema (ref. 3). The authors examined 51 patients with a BMI over 30, and with no other pre-existing condition or risk-factor associated with lymphedema. All patients with a BMI over 60 had an abnormal lymphoscintigram (a test for lymph flow) characteristic of lymphedema, while all patients with a BMI under 50 had normal lymphoscintigrams. This suggests that there may be a threshold of 50-60 BMI, above which lymphedema of the legs may become all but a certainty.
But this threshold also depends on other factors, and so for some individuals the BMI threshold for developing lymphedema would be expected to be much lower than 50-60. This group would include people with undiagnosed preexisting lymphatic deficiencies arising from cancer treatment, injury, or who were born with a congenital lymphatic malformation (but who are currently symptom free). For this group a much more modest increase in body weight might be enough to tip the scales in favor of developing lymphedema.
The existence of preexisting lymphatic deficiencies in otherwise outwardly healthy individuals might help explain an interesting observation reported in this study: in 25% of cases of lymphedema believed to be caused by obesity, lymphedema was found to affect only a single leg, rather than both as might otherwise be expected.
How common is lymphedema in people who are obese?
Studies suggest that the frequency of lymphedema in overweight individuals who are otherwise healthy should increase with body mass index (BMI). Having a BMI of over 30 appears to place you at heightened risk of lymphedema, whereas if you have a BMI of 50-60 or more, you are at very high risk.
As populations in the developed world grow progressively more obese, lymphedema caused by obesity should therefore become more prevalent. For that matter, shouldn’t we already be seeing an epidemic of obesity-related lymphedema in the heaviest of nations?
A German study published this month appears to offer early evidence of this (ref. 4). The authors found that prescription of manual lymphatic drainage (a treatment for lymphedema) is increasing in Germany disproportionate to the burden of lymphedema, and instead correlates with a growing prevalence of obesity in that country.
As awareness of obesity-related lymphedema grows, along with interest and capacity to measure and track it, we are likely to discover that it is already very prevalent in our population.
Why would obesity cause lymphedema?
Lymphedema is the persistent accumulation of excess lymph fluid in a tissue or limb. Tissues of the body are continuously bathed in fluid, some of which returns to the heart via the venous system, while the remainder is collected by the lymphatic system. Any disruption of the lymphatic system should therefore cause an accumulation of fluid in the affected area. It is hypothesized that excess fat deposits in the legs might physically compress lymph vessels and thereby reduce lymph collection, much like pinching a drinking straw would prevent you from drinking. But this is not likely to be the whole story.
For obese individuals a combination of factors is likely at play. In addition to a physical compression of lymphatic vessels by fatty tissue, local inflammation caused by the presence of excess fat is hypothesized to further damage the vessels. To make matters worse, obese individuals are especially susceptible to overburdening their lymphatic systems to begin with, in particularly in the legs and feet where fluid is naturally prone to accumulate. This is due to the fact that excess fat increases the body’s production of lymph (so there is more to contend with in the first place), and can also promote venous insufficiency, a condition that in itself causes swelling.
If I reduce my BMI will my lymphedema go away?
The answer appears to be maybe. The 2015 study looked retroactively at patients who once had a BMI over 60 but who had since reduced their BMI to below 50. In this subpopulation some patients had lymphedema, while others did not, suggesting that perhaps a subpopulation could recover completely, but this data is far too weak and speculative to draw definitive conclusions.
To further explore the hypothesis that obesity-induced lymphedema could be irreversible the authors of this paper followed it up with a second very small qualitative study where they measured lymphatic function for one significantly overweight patient before and after weight loss surgery. The patient went from a very high BMI of 80 to a BMI of 36 18 months later, and no improvement in lymphatic function was observed by lymphoscintigraphy (ref. 5).
Considering the underlying physiology of the lymphatic system, it seems probable that lymphedema would subside only in those patients where the underlying lymphatic architecture has not (yet) been irreparably damaged. Given that lymphedema is typically both a chronic and progressively worsening condition, it is reasonable to expect that the sooner a patient can reduce their weight, the greater their chances will be of a full recovery. Unfortunately, if sufficient permanent damage to the lymphatic system has already taken place, life-long lymphedema management will be required.
I’m obese – now what?
Reduce your BMI
The accumulating evidence strongly suggests that patients with a BMI of over 30 are likely at an increased risk of lymphedema, particularly if they have preexisting lymphatic insufficiency that is currently asymptomatic, such as those who have undergone cancer treatment such as lymph node dissection, radiation, and chemotherapy.
All individuals should certainly attempt to keep their BMI below 50 (something that is advisable for a myriad of health reasons), or they will be at high risk of developing a potentially irreversible lower extremity lymphedema.
This is certainly not as easy as it sounds, and unfortunately, might in fact be more difficult than normal if your lymphatic drainage has already started to weaken. New research suggests that weakened lymphatic drainage promotes fat storage even before noticeable swelling is present. The study in question demonstrated that microenvironmental changes in adipose tissue caused by weakend lymphatic drainage actually discourages the tissue from converting fat into energy – both while at rest and in response to exercise. Since fat will in turn exacerbate #lymphedema, this finding reinforces the necessity of maintaining a healthy body weight.
Monitor for the symptoms of obesity-related lymphedema
Lymphedema caused by obesity usually occurs in the legs, and for perhaps three quarters of patients, both legs simultaneously.
At early stages of the condition swelling appears much like other forms of swelling. For example, you should be able to push on an area of swelling with your finger and make a small temporary indent (called the ‘pitting’ test). Swelling will also tend to be reduced or absent in the morning and worsen throughout the day. At later stages of the condition, tissue hardening occurs making the swelling feel denser and the limb feel heavier.
Lymphedema of the legs also typically includes the feet. To help you determine if your feet are swollen you can perform the ‘Stemmer’s sign’ test. Pinch and lift the skin on top of the foot in the area where your toes connect to your foot. If you are able to pinch and lift the skin, then you do not have fluid swelling or fibrosis in your feet and are therefore less likely to have lymphedema.
Unfortunately, the symptoms of lymphedema can be more difficult to identify in an obese individual due to larger limb size. These individuals may also suffer from other conditions that present with similar symptoms such as venous insufficiency or lipedema (see our patient guide to self-diagnosing lipedema), making accurate diagnosis more difficult.
If you are obese, in particular if you are approaching a BMI of 50, discuss lymphedema with your family doctor to make sure they are aware of your increased risk of developing this condition. Your family doctor may have little or no experience with lymphedema, and so you should not expect this condition to be top of mind for them.
If you suspect lymphedema, don’t wait to seek help
If you are overweight and are experiencing fluid swelling in your legs talk to your doctor about your symptoms and the possibility of lymphedema.
If lymphedema is suspected, seek professional help for reducing your bodyweight. Some degree of weight loss is critical in order to relieve the pressure on the lymph vessels and hopefully regain normal lymphatic function before irreversible damage is done. Even if your swelling has already become permanent, weight-loss will reduce your symptoms and help prevent further disease progression.
Individuals with suspected lymphedema should also seek out a specialist trained in Complex (or ‘Combined’) Decongestive Therapy (CDT), the international gold standard treatment for lymphedema.
A CDT therapist can help reduce the swelling and limb size through manual drainage techniques and compression garments, provide education on reducing the risk of infection and exercises specific to the lymphatic system, and offer guidance for ongoing self-monitoring and self-management of the condition.
While lymphedema awareness is growing, the link between bodyweight and lymphedema remains largely underappreciated. Consequently, overweight individuals who suspect they have lymphedema must be strong self-advocators and self-educators.
References
- Greene, A.K., et al. Lower-Extremity Lymphedema and Elevated Body-Mass Index. N Engl J Med. 2012; 366:2136-2137 article
- Helyer, L.K., et al. Obesity is a risk factor for developing postoperative lymphedema in breast cancer patients. Breast J. 2010 Jan-Feb; 16(1):48-54. abstract
- Greene, A.K., et al. Obesity-Induced Lymphedema: Clinical and Lymphoscintigraphic Features. Plast Reconstr Surg. 2015; Feb 20 Epub ahead of print. abstract
- Kroger, K., et al. Correlation between obesity and manual lymphatic drainage in Germany – a retrospective analysis from 2008 to 2016. Vasa. 2019 Dec 6:1-6 Epub ahead of print. abstract
- Greene, A.K., et al. Obesity-induced Lymphedema Nonreversible following Massive Weight Loss. Plast Reconstr Surg Glob Open. 2015 Jul8;3(6). abstract
My gen practician does not seem to think this lump is important. After a very painful test for blood clot my entire leg was severely bruised and this restricted blood flow or maybe lymph movement and I am obese. Don’t know what type of dr to consult but I am very concerned. I have pics of the dmg from the ultra sound. Pls give me some advice who to see
Hello Mj,
I’m so sorry to hear of your painful leg and the bruising and swelling that you have with it. I’m glad if the test for a blood clot was negative. If you feel you have lymphedema, which is common in those who are obese, then I would recommend you see a therapist who is trained in manual lymphatic drainage massage. They will be able to help you with skin care advise to decrease the risk of infection, compression stockings to help keep your leg more comfortable and to decrease swelling, and drainage massage to further assist. If there is a lump that has been biopsied and which came back negative, then it’s possible the pain you feel is more from the swelling? It’s difficult to say. I do hope you find someone who can be of help Mj. Sincerely, Lindsay Davey
How would you know if you have permanent lymphatic damage? My lymphadema is from obesity I got to 289 lbs. I wrap my feet and calves, also use compression garments. I have also recently lost 22 lbs and will not stop until all this extra weight is gone. I just hope it’s not to late.
Great job on losing 22lbs! Keep it up :) The only real way to know if obesity-related lymphedema has caused permanent damage to your lymphatics is to lose weight and see if your swelling goes away, and stays away. The good news is that even if you have experienced some permanent damage, you MAY still be able to reduce your level of excess fat to a point where your lymphedema goes away regardless! This is because the less fat that you have in your legs, the less fluid your lymphatic system will have to remove (fluid follows fat into your legs), so a partially damaged lymphatic system may not be able to handle your current fluid load, but may still be able to process quite effectively the more “normal” fluid levels found in legs with less fat. In other words you may (1) not have damaged your lymphatics at all (hopefully); (2) you may have damaged them to a point where you are only susceptible to lymphedema under circumstances where they are under excess load (such as if you sprain your ankle, or if you have high leg fat); or (3) you may have caused enough damage to have chronic lymphedema even once your legs achieve a more healthy fat level. Regardless of which situation you are in, reducing your excess leg fat should reduce the swelling in your legs. Every pound of excess fat you lose decreases your risk of (further?) damage to your lymphatics AND decreases the day-to-day fluid burden on your lymphatics, thus making them function more effectively – a positive spiral of change :)
I believe I have an undiagnosed lymphatic mass that is protruding from my stomach that hangs almost to my knees. I am morbidly obese, my PCM did not examine me, just sent me to a plastic surgeon who also said he couldn’t help and did not physically examine it. I also deal with acne inversa which has caused a lot of pain due to cysts growing on the mass. I’m not sure what type of doctor I need to go to. It feels like an anchor tied to me and it makes getting around painful and very limited due to back pain. Please help guide me in the right direction.
Hello Kimberly,
I’m so very sorry to hear that you’ve had trouble accessing the care and assessment you’re in need of. I would suggest speaking to another plastic surgeon who would examine you thoroughly, if this wasn’t done in your visit with the one you were sent to. They would be the professional with the most expertise in this area. I unfortunately can’t comment on the cysts per se, but again, I feel a plastic surgeon would be the best starting point. Wishing you luck in accessing a thorough assessment. Lindsay Davey
I had a DVT 2016. Afterwards I developed post thrombotic syndrome. I also have varicose veins. In 2017 I developed a stasis ulcer on that post DVT leg. After the wound healed the vein clinic I was going to suggested collapsing the greater saphenous veins in bilateral legs. They did, and also injected foam in the branch-off varicosities over a few weeks.
Since then I have developed lymphedema in my bilateral lower extremities. I use a flexitouch compression devise and I wear farrow wraps on my calves. The problem I have now are my thighs. I can’t seem to find anything to keep the swelling down. I am very overweight. I’ve recently lost 38 pounds and continuing to try dieting. I started yoga recently.
What Dr can I go to that can help me with my thighs? It impedes my walking and quality of life seems to just keep getting worse due to movement issues.
Hi Sarah,
I’m so sorry to hear of the DVT and surgical/interventions that were required since then. Well done on the weight loss and yoga, both have been proven to help a great deal with lymphatic flow and volume reduction. In terms of a physician who specializes in lymphedema – you’re right, this is difficult to find. In some cities, it is a vascular surgeon (so perhaps yours could refer you to someone?), a dermatologist, a physiatrist, or even some GP’s. If you can access an experienced CDT therapist, they are likely your best bet, though I presume you have given you are already using Farrow Wraps and have some compression garments already in place. We tend to recommend one of a few strategies for the thighs – provided the compression on the lower legs is sufficient enough, you could use traditional bandaging for the upper thighs to try to get volume reduction (with a CDT therapist), compression shorts are available that can cover the thigh region (again, only if used with compression for the lower legs that creates a full-leg compression scenario with the compression shorts up top), or a custom made pantyhose style, possibly once your legs are a bit smaller overall. An experienced compression garement fitter, and lymphedema therapist, would surely be able to evaluate your legs and provide their best solution options to you. I’m sorry that physicians that specialize in this area are very difficult to find. I wish you all the best Sarah, and hope that the yoga and weight loss continue to provide meaningful benefit to both the lymphatic and venous flow in your legs. Lindsay Davey
I should also add, that EdemaWear is a product that we sometimes use which is a light stockinette weave type item, that while has quite a low compression level, may be indicated in some cases to help with providing at least some support until a more long-term solution is possible. All the best Sarah!
Lindsay
My mother had a swollen lower calf. After a number of tests, she was diagnosed with a burst cyst and continued for two weeks without relief, until it became too much and her doctor admitted her to hospital. Following further tests, she was correctly diagnosed with lymphedema. Unfortunately she is elderly and obese. Cancer she had in 2018 has also reoccurred. I hope she can recover but from reading your article , it doesn’t seem hopeful. I wish we’d know about this condition before. After two hospital visits and one specialist visit, they still didn’t diagnose it. More awareness of this is needed.
Hello Louise,
I’m sorry to hear of your mother’s course of care in the determination of her lymphedema. Calf swelling can present in a multitude of different conditions/issues, lymphedema being one of them, as she finally determined was the cause in her case. With obesity as a confounding variable, it can be difficult to recovery lymphatic drainage in the lower leg if the lymphatics (vessels) have been compromised by the excess body fat, and/or if stagnant fluid has caused tissue changes/fibrosis in the area, and so on. Venous return may also be compromised in the lower leg in someone who is obese and/or not that mobile, and these multifaceted cases are certainly a challenge. I do hope that she can get some relief from a certified therapist who would be able to provide hands-on massage to soften the area if it is hardened at all, to help promote flow/fluid return, to direct her as to the pumping exercises that can help activate her own drainage, and bandaging/compression garments as needed to help with decreasing the size/volume of the leg. Wishing her all the best, and I agree, more awareness is certainly needed. Thank you again for your comments Louise. Lindsay Davey
Hello, I am a lymphedema therapist in Dallas clinic. I work in a clinic with 4 other Vodder-certified lymphedema therapists. We are trying to develop a “cut off” point where we will refer a patient for weight loss prior to treatment.
Do you use one in your clinic? Can you share what it is and especially any literature to justify it.
Hello Debra,
Thank you for your question. We do not use a cut off in terms of BMI prior to treating our patients, no. I would argue that any assistance in reducing swelling or tissue changes is critical in order to help prevent the progression of the lymphedema, and will assist patients which a high BMI concurrently with their weight loss goals. We certainly educate patients the role between obesity and lymphedema, but would not withhold treatment while waiting for a weight loss goal to be achieved. Best of wishes, Lindsay Davey
Hi Dr. Davey, thank you so much for your comprehensive info about lymphedema. I’ve been obese my adult life (I’m 54) but have recently gone from a BMI of 50 to 41 after losing 70lbs over the course of a couple of years. One other background point… earlier this year (January) I had surgery to remove a recurring breast abscess, also on the right side. I don’t know if they did anything to biopsy a lymph node, though.
Anyway, since warmer weather now has me in short sleeves, I’ve only recently noticed that my right upper arm is considerably larger than the left–3 inches larger in circumference. I’ve also noticed that my right thigh is larger than my left. Not as much as 3 inches but it is bigger. There’s no pain involved. Weirdly, I seem to have symptoms of both lymphedema and lipedema. I have the unilateral nature of the former, but the non-swollen ankles/wrists, non-pitting fat and tiny bead-like lumps of fat of the latter. (Also negative on the Stemmer sign–I can lift skin of my toes/feet and fingers/hand.)
I’m making an appt. w/my GP, but was wondering 1) if you know if lipedema is ever unilateral? And also: 2) for as long as I can remember, I’ve slept exclusively on my right side, and when largely immobile due to my weight, I spent most of my days lying on that side as well. Is it possible for this constant compression/pressure to cause issues with swelling or asymmetry of fat distribution?
I’m hoping that whatever this is has been caught relatively early. Thanks again for all these resources!
Hello Kira,
Thank you for sharing your story and my sincere apologies for the delayed reply. If you are noticing in the warmer weather that the right upper arm is considerably larger than the left arm, and this is the same side that 6 months ago you had surgery on this side (at the breast) – I would pursue this with your family physician, at least to understand whether or not they did remove any lymph nodes in the abscess removal process. If so, you could be experiencing lymphedema, which can be aggravated by warmer temperatures, high BMI, and node removal, so you may have a few risk factors that could lend itself to the presentation of lymphedema. Any time we have a swelling that is on one side only and particularly if no nodes were removed during your surgery, we do recommend having a physician assess it, to make sure other reasons for unilateral swelling are ruled out (blood clot, for example).
It is entirely possible that you do have a dual presentation going on – lipedema and lymphedema, as these can indeed be co-incident. Lipedema is not typically unilateral however, no (though one arm or leg could be ‘worse’ than the other, to some extent, it would be rare if it was present on one side and absent on the other). Sleeping on one side would not typically cause or drive a unilateral swelling, if anything, compression on the right side may very well help prevent swelling, though this would depend on whether it is a lymphedema in its nature, or other aetiology of swelling.
I would suggest given what you’ve described that you do rule out other causes of swelling in the right upper arm with your physician, and determine whether you have had nodes removed from this armpit or not, as this will be informative for the future as to whether or not you are at risk of secondary lymphedema or not.
Best wishes Kira! I hope this helps unmuddy the waters a bit.
Lindsay Davey
Have you discovered through studies and/or experience that lymphedema impedes weight loss? I have been a long time lymphedema patient. I’ve been consistently increasing water intake (now at about 60+ oz per day) and using an app to count macros every day for 50 days. I’ve eaten under my numbers about 90% of that time.Because of water retention, my weight loss has fluctuated between 3 to 7 pounds of weight loss. Is it typical for me to go up and down while generally losing?
Hello Teresa,
Thank you for your question. While we don’t follow our lymphedema patients in terms of their weight loss programs/achievements, per se, I would say that an individual with significant swelling (for example, both legs, or a singular leg but which is significantly lymphedematous) would see a ‘diluted’ impact to their weight loss interventions, yes, due to the fact that so much lymphatic fluid is retained. While weight loss can certainly help the symptoms and extent of primary lymphedema in general terms (off-loading the lymphatics and tissues via reducing the adipose component and thus, helping lymphatic and venous flow), if there is a significant volume of lymphatic fluid accumulation in your tissues, yes, I would certainly expect some fluctuation in the weight loss trajectory. Perhaps someone in our readership could comment as to their experience as well. Best wishes Teresa! Lindsay Davey