There is a growing epidemic in the United States, actually it almost might be referred to as a pandemic. That is the skyrocketing incidents of obesity, not only among adults, but also among children.
We are also seeing an increase in reported cases of lymphedema as a secondary condition caused by obesity. Obesity and especially morbid obesity causes lymphedema by crushing and/or overwhelming the lymphatics.
In an article, “Obesity and cancer: the risks, science, and potential management strategies,” Anne McTiernan, MD, PhD, from the Prevention Center, Fred Hutchinson Cancer Research Center in Seattle, WA, wrote: “The data from our survey suggests that lymphedema is more severe among those with higher body weight and that infections of the skin were much more common among patients with LE who were overweight. In addition, those who were overweight were more likely to have physical limitations that impaired their ability to conduct daily activities.”
For information on healthy dietary ideas and suggestions see The Lymphedema Diet
“Morbid obesity” is a clinical term for a medical condition. It is not meant to be an offensive term, but to some it is. Obesity is excess body weight resulting from eating too much and exercising too little. For some it may be caused by genetic factors. Obesity is the second leading cause of preventable death. It may soon become the number one cause overtaking cigarette smoking. Obesity is now considered a chronic medical disease with serious health cost. Though we all use the terms “fat” and “obese” casually in conversation, there is a medical definition of the condition—and yes, obesity is considered a health “condition.”
According to the National Institutes of Health (NIH), a person is considered “obese” when he or she weighs 20 percent or more than his or her ideal body weight. At that point, the person's weight poses a real health risk. Obesity becomes “morbid” when it significantly increases the risk of one or more obesity-related health conditions or serious diseases (also known as co-morbidities). Morbid obesity—sometimes called “clinically severe obesity”—is defined as being 100 lbs. or more over ideal body weight or having a Body Mass Index (BMI) of 40 or higher.
According to the NIH Consensus Report, morbid obesity is a serious chronic disease, meaning that its symptoms build slowly over an extended period of time. Today 97 million Americans, more than one-third of the adult population, are overweight or obese. An estimated 5-10 million of those are considered morbidly obese.
Morbid obesity is defined as an individual having a BMI (body mass index) of 39.
Morbid obesity is linked with progressive, serious diseases called co-morbidities such as:
Adult onset diabetes
Osteoarthritis of weight bearing joints
Sleep apnea or other respiratory problems
Acid reflux (heartburn)
Certain types of cancer
Other serious disorders
Another list of comorbities associated with obesity and morbid obesity includes:
Cardiovascular: congestive heart failure, enlarged heart and its associated arrhythmias and dizziness, cor pulmonale, varicose veins, and pulmonary embolism
Endocrine: polycystic ovarian syndrome (PCOS), menstrual disorders, and infertility
Gastrointestinal: gastroesophageal reflux disease (GERD), fatty liver disease, cholelithiasis (gallstones), hernia, and colorectal cancer
Renal and genitourinary: erectile dysfunction, urinary incontinence, chronic renal failure, hypogonadism (male), breast cancer (female), uterine cancer (female), stillbirth
Musculoskeletal: hyperuricemia (which predisposes to gout), immobility, osteoarthritis, low back pain
Neurologic: stroke, meralgia paresthetica, headache, carpal tunnel syndrome, dementia
Respiratory: dyspnea, obstructive sleep apnea, hypoventilation syndrome, Pickwickian syndrome, asthma
Psychological: Depression, low self esteem, body dysmorphic disorder, social stigmatization
By Crystal Phend
LAS VEGAS, N.V. – May 2, 2006 – Obesity appears to increase the risk of developing lymphedema after axillary lymph nodes are removed for breast cancer, according to a study presented here at the annual meeting of the American Society of Breast Disease (ASBD).
“Patients need to be informed of this risk,” said lead author Lucy K. Helyer, MD, surgical oncology fellow, Princess Margaret Hospital University Health Network, Toronto, Ontario, Canada, in a presentation on April 28th.
In Dr. Helyer's study, increasing lymphedema rates were seen with increasing body mass index (BMI). About 36% of obese patients had the condition compared to about 16% of overweight patients, about 7% of normal weight patients and no underweight patients.
Lymphedema, chronic swelling caused by build up of lymphatic fluid, is a frequent complication of breast cancer therapy.Arm lymphedema occurs in anywhere from 6% to 62% of breast cancer patients depending on measurement methodology and follow-up time, Dr. Helyer said.
Patients' arm volumes were measured before surgery and every 6 months afterward for 24 months, and their subjective complaints of lymphedema symptoms were reviewed. All symptomatic patients were treated with arm elevation, compression sleeve and massage.
Lymphedema was defined as an arm immersion volume increase >200 mL compared to the patient's other arm. The researchers used World Health Organization definitions for BMI, with 25 to 29.2 considered overweight and 30 or more classified as obese.
Most of the patients had received lumpectomy (132) and less than half had received sentinel lymph node biopsy without axillary lymph node biopsy (54). The average number of sentinel lymph nodes removed was 3.55 and the average number of axillary lymph nodes dissected was 11.66.
Axillary lymph node dissection was associated with more arm volume change at all time points compared to sentinel lymph node biopsy alone, but this was not a significant difference.
“Symptomatic lymphedema occurs in one third of patients with objective lymphedema, often without a precipitating event,” Dr. Helyer noted
We previously reported on a correlation between weight and lymphedema (see Dr. Reid's Corner-Complete Obesity Survey Results and eNews August 2001). New research links effective weight management with a reduction in breast cancer risk (1). We have known for many years that effective weight control can reduce the risk for diabetes, heart disease and blood pressure. But this new data now adds reduced risk of breast cancer to the list of benefits derived from effective weight control. The link between breast cancer and obesity seem to be higher estrogen levels among women with higher body weights. The ovaries produce estrogen. But, at menopause the production of estrogen from the ovaries decreases. Among postmenopausal women, most of the estrogen comes from fat tissue and women who are overweight can have significantly more circulating estrogens than women with normal body weight. Since the risk of breast cancer is associated with estrogen exposure, it was hypothesized that overweight women may be at higher risk for breast cancer. In two separate studies, women who were more than 22 to 55 pounds above their ideal weight were at significantly greater risk of developing breast cancer. The researcher suggests that as much as 15% of breast cancer may be due to obesity. On the positive side, women who reduced their weight by 22 pounds or more during menopause and kept the weight off were less likely to develop breast cancer.
I have been interested in the effects of obesity on lymphedema for many years and we have been conducting an on line survey that seeks to evaluate the physical and emotional effects of lymphedema. We reported the results of this survey at previous meetings of the NLN and at the San Antonio Breast Cancer meeting. The data from our survey suggests that lymphedema is more severe among those with higher body weight and that infections of the skin were much more common among patients with lymphedema who were overweight. In addition, those who were overweight were more likely to have physical limitations that impaired their ability to conduct daily activities. In our survey, it was notable that there was no correlation between weight and the amount of emotional support the patients received from their families and friends and most patients remained optimistic that they could overcome the problems associated with lymphedema.
We continue to collect data on the correlation between lymphedema and obesity and will be updating our findings later this year. Anyone who is interested in contributing to this effort and has not already submitted a response to our survey can do so here.
Our experiences in treating lymphedema shows that obesity is not only a contributing factor to breast cancer risk, but also contributes to the risk of developing lymphedema. In addition, the severity of lymphedema is correlated with obesity. Our experience also mirrors the results reported for breast cancer risk. We also find that effective control of lymphedema can be more effectively achieved and maintained among the patients who are also able to effectively reduce excess body weight. While obesity is not the only factor contributing to the risk of lymphedema it is an important and potentially controllable factor. Effective weight management coupled with effective treatment may help many patients suffering from the effects of lymphedema.
Tony Reid MD, Ph.D.
Obes Surg. 2006 Sep
Modolin ML, Cintra W Jr, Paggiaro AO, Faintuch J, Gemperli R, Ferreira MC. Plastic Surgery, Hospital das Clinicas, São Paulo, SP, Brazil. email@example.com
BACKGROUND: Mild lymphedema of lower limbs and eventually abdomen is not exceedingly rare in morbid obesity. However, few large symptomatic masses have been reported. In a consecutive series of patients, all requiring resection of the lesion before bariatric treatment, clinical features and surgical findings are described, aiming to clarify the nature of this intricate problem.
METHODS: Subjects (n=4, 50% females, age 34.0+/-13.7 years (19-53), BMI 56.4+/-10.5 kg/m(2) (44.1-73.1) displayed lesions on the anteromedial aspect of the thigh (n=3) and hypogastrium (n=1). All reported episodes of intertrigo of local skin-folds in the preceding years, managed by local care and antibiotics. The mass was described as a serious nuisance, impairing walking, dressing and personal hygiene.
RESULTS: The mass was surgically removed without requirement for blood transfusion except in the case of one huge mass. Complications were relatively minor and consisted of partial skin dehiscence and lymph leakage for 2-3 weeks. Histologically, a complex pattern was observed including skin hypertrophy, edema, fibrosis, foci of microabscesses and dilated blood vessels, along with the pathognomonic lymphangiectasia. On follow-up to 6 months, improvement or restoration of the ability to walk occurred, with no additional skin infection and no recurrence.
CONCLUSIONS: 1) Surgical treatment was effective. 2) Functional rehabilitation was achieved. 3) No recurrence was observed within the follow-up period.
PMID: 16989693 [PubMed - indexed for MEDLINE]
Archives of Pathology & Laboratory Medicine, Apr 2001 by Azam, Muhammand, Saboorian, M Hossein, Bieligk, Samuel, Smith, Todd, Molberg, Kyle
Herein, we report a case of cutaneous angiosarcoma in a 35-year-old, morbidly obese woman. The tumor arose in the most dependent portion of the lower abdominal panniculus and showed typical changes of chronic lymphedema. The patient underwent a radical resection of her lower abdominal wall panniculus, which showed a multicentric, high-grade angiosarcoma with bilateral superficial inguinal lymph node metastases. Histologically, conventional vasoformative areas were admixed with poorly differentiated sheets of spindle and epithelioid cells. Factor VIII was focally positive (membranous), whereas CD31 showed robust, diffuse positivity (membranous and cytoplasmic). The initial margins of resection were negative, and no follow– up radiation or chemotherapy was given. Following a recurrence at the previous excision site, the patient died 7 months after the surgery. Postmortem examination revealed a widely metastatic tumor that involved multiple organ systems. We believe this is the second report of cutaneous angiosarcoma occurring in a chronically lymphedematous abdominal panniculus due to morbid obesity. (Arch Pathol Lab Med. 2001;125:531-533)
Ostomy Wound Manage. 2008 Jan
Fife CE, Carter MJ. Department of Anesthesiology, University of Texas Health Science Center, Houston, Texas, USA. Caroline.E.Fife@uth.tmc.edu
The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. A 5-year retrospective review of data (2000-2005) shows that the percentage of patients >350 lb in the authors' clinic population increased from approximately 7% to 11% and 75% of their morbidly obese patients (body mass index >40) had or have lymphedema. After a differential diagnosis between lipedema and lymphedema (primary or secondary) has been made, lymphedema management options include compression bandaging, manual lymphatic drainage, and localized surgeries. The treatment of morbidly obese lymphedema patients requires additional staff time and specialized equipment to move or position them and may be confounded by other conditions (eg, heart failure and venous insufficiency) that contribute to edema. Lymphedema treatments have been found to be useful, providing patients are able to follow treatment guidelines, especially with regard to weight control. In the authors' experience, massive localized lymphedema will recur unless the primary issue of obesity is addressed. Establishing clear criteria and patient participation guidelines before initiating a comprehensive localized lymphedema program will improve outcomes.
Ostomy Wound Manage. 2008 Jan
Fife CE, Benavides S, Carter MJ. University of Texas Health Science Center, Houston, Texas, USA. Caroline.E.Fife@uth.tmc.edu
The prevalence of morbid obesity, along with related comorbidities, is dramatically increasing in the US, confounding wound care for persons at heightened risk for skin compromise. The purpose of this overview is to examine common concerns related to morbid obesity and interrelated lower extremity complications, including wound and skin infections, dermatologic conditions, lymphovenous obstruction syndromes, chronic venous insufficiency, and anatomical abnormalities such as massive localized lymphedema. Treatment may include surgery for massive lymphedema localizations, compression bandaging for chronic venous insufficiency as well as lymphedema, manual lymph drainage for lymphedema, and prompt and aggressive management of wound infection and bioburden. Case studies are presented to illustrate some lower extremity complications of morbid obesity and appropriate protocols of care. Although increasing evidence suggests that morbidly obese patients are predisposed to secondary lymphedema and that primary lymphedema can cause adult-onset obesity, the mechanisms by which these events occur remain unclear. However, unless the underlying problem of morbid obesity is addressed, the problems for which these patients seek care will continue to recur.
A growing method of weight control and loss is the use of surgery to either by-pass the stomach or to seriously restrict its ability for food intake. This section will give you a review of the available surgeries and links for further information.
It is important to understand the procedures and risks associated with weight loss surgery as well as the commitment required of the patient. Referral to the Bariatric program by the patient's doctor or one of our Bariatric surgeons is required. In addition, a patient must meet set requirements to enter the program.
The LAP-BAND® System is a silicone elastic ring designed to be placed around the upper portion of the stomach and filled with saline. This creates a “new stomach” and leaves the larger part of the stomach below the band. The LAP-BAND® System is a tool to help you achieve sustained weight loss by limiting how much you can eat, reducing your appetite and slowing digestion.
A very small pouch is formed with staples
The rest of the stomach is completely separated and closed with staples
A section of the small intestine is attached to the “pouch” to maintain flow
Weight loss occurs due to the small amount of storage area in the new stomach pouch. The short part of the small intestine that is bypassed cannot use nutrients. This causes food to be poorly digested and absorbed (malabsorption). Less absorption will cause weight loss.
The amount of food or liquid that can be eaten is limited to the storage size of this small pouch. Patients are forced to limit the amount and kind of food or fluid that can be taken in at one time. Nearly all patients report feeling full and satisfied most of the time.
Eating more than a quarter cup of food at once, may result in:
Rupture of the stomach staple line cause major complications
The stomach and a portion of the small intestines are “by-passed”. This causes poor use of nutrients. The following must be taken on a daily basis for life to prevent nutritional problems:
High protein intake (1) http://www.mtmc.org/bariatricsurgery.php Middle Tennessee Medical Center
New England Journal of Medicine - August 2007
Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects
Lars Sjöström, M.D., Ph.D., Kristina Narbro, Ph.D., C. David Sjöström, M.D., Ph.D., Kristjan Karason, M.D., Ph.D., Bo Larsson, M.D., Ph.D., Hans Wedel, Ph.D., Ted Lystig, Ph.D., Marianne Sullivan, Ph.D., Claude Bouchard, Ph.D., Björn Carlsson, M.D., Ph.D., Calle Bengtsson, M.D., Ph.D., Sven Dahlgren, M.D., Ph.D., Anders Gummesson, M.D., Peter Jacobson, M.D., Ph.D., Jan Karlsson, Ph.D., Anna-Karin Lindroos, Ph.D., Hans Lönroth, M.D., Ph.D., Ingmar Näslund, M.D., Ph.D., Torsten Olbers, M.D., Ph.D., Kaj Stenlöf, M.D., Ph.D., Jarl Torgerson, M.D., Ph.D., Göran Ågren, M.D., Lena M.S. Carlsson, M.D., Ph.D., for the Swedish Obese Subjects Study
Background Obesity is associated with increased mortality. Weight loss improves cardiovascular risk factors, but no prospective interventional studies have reported whether weight loss decreases overall mortality. In fact, many observational studies suggest that weight reduction is associated with increased mortality.
Methods The prospective, controlled Swedish Obese Subjects study involved 4047 obese subjects. Of these subjects, 2010 underwent bariatric surgery (surgery group) and 2037 received conventional treatment (matched control group). We report on overall mortality during an average of 10.9 years of follow-up. At the time of the analysis (November 1, 2005), vital status was known for all but three subjects (follow-up rate, 99.9%).
Results The average weight change in control subjects was less than ±2% during the period of up to 15 years during which weights were recorded. Maximum weight losses in the surgical subgroups were observed after 1 to 2 years: gastric bypass, 32%; vertical-banded gastroplasty, 25%; and banding, 20%. After 10 years, the weight losses from baseline were stabilized at 25%, 16%, and 14%, respectively. There were 129 deaths in the control group and 101 deaths in the surgery group. The unadjusted overall hazard ratio was 0.76 in the surgery group (P=0.04), as compared with the control group, and the hazard ratio adjusted for sex, age, and risk factors was 0.71 (P=0.01). The most common causes of death were myocardial infarction (control group, 25 subjects; surgery group, 13 subjects) and cancer (control group, 47; surgery group, 29).
Conclusions Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality.
Volume 357:753-761 August 23, 2007 Number 8
Long-Term Mortality after Gastric Bypass Surgery
Ted D. Adams, Ph.D., M.P.H., Richard E. Gress, M.A., Sherman C. Smith, M.D., R. Chad Halverson, M.D., Steven C. Simper, M.D., Wayne D. Rosamond, Ph.D., Michael J. LaMonte, Ph.D., M.P.H., Antoinette M. Stroup, Ph.D., and Steven C. Hunt, Ph.D.
Background Although gastric bypass surgery accounts for 80% of bariatric surgery in the United States, only limited long-term data are available on mortality among patients who have undergone this procedure as compared with severely obese persons from a general population.
Methods In this retrospective cohort study, we determined the long- term mortality (from 1984 to 2002) among 9949 patients who had undergone gastric bypass surgery and 9628 severely obese persons who applied for driver's licenses. From these subjects, 7925 surgical patients and 7925 severely obese control subjects were matched for age, sex, and body-mass index. We determined the rates of death from any cause and from specific causes with the use of the National Death Index.
Results During a mean follow-up of 7.1 years, adjusted long-term mortality from any cause in the surgery group decreased by 40%, as compared with that in the control group (37.6 vs. 57.1 deaths per 10,000 person-years, P<0.001); cause-specific mortality in the surgery group decreased by 56% for coronary artery disease (2.6 vs. 5.9 per 10,000 person-years, P=0.006), by 92% for diabetes (0.4 vs. 3.4 per 10,000 person-years, P=0.005), and by 60% for cancer (5.5 vs. 13.3 per 10,000 person-years, P<0.001). However, rates of death not caused by disease, such as accidents and suicide, were 58% higher in the surgery group than in the control group (11.1 vs. 6.4 per 10,000 person-years, P=0.04).
Conclusions Long-term total mortality after gastric bypass surgery was significantly reduced, particularly deaths from diabetes, heart disease, and cancer. However, the rate of death from causes other than disease was higher in the surgery group than in the control group.
Vasileiou AM, Bull R, Kitou D, Alexiadou K, Garvie NJ, Coppack SW.
East London Obesity Service, Barts and The London Medical School, Homerton University Hospital and Nuclear Medicine, The Royal London Hospital, London, UK.
Oedema is a common finding in obesity and its cause is not always clear. Possible causes include impairment of cardiac, respiratory and/or renal function, chronic venous insufficiency and lymphatic problems. Lymphoscintigraphy is the best method to detect structural lymphatic abnormalities that can cause lymphoedema. We reviewed 49 female subjects with pitting oedema who had undergone lymphoscintigraphy, divided in three groups.
The first group was comprised of severely obese patients in whom cardiorespiratory causes for oedema had been excluded. The second group consisted of non-obese patients with recognized causes for oedema and the third group was non-obese patients with 'idiopathic' oedema. A standard classification was used to interpret lymphoscintigraphy results. The frequency and severity of lymphoscintigraphic abnormalities was greatest in patients with clinical diagnoses of oedema related to 'recognized causes' (any abnormality in 50% of legs with obstruction in 22%).
Obese patients and those with 'idiopathic'oedema had fewer (P=0.02 for both) and milder lymphoscintographic abnormalities (any abnormality 32 and 25%, respectively, obstruction 5 and 3%, respectively), and although the clinical oedema was invariably bilateral, the lymphoscintigraphy abnormalities were usually unilateral.
In conclusion, structural lymphoscintigraphic abnormalities are uncommon in obesity and do not closely correlate with the clinical pattern of oedema.
ICD-9-CM Diagnosis 278.0
Body weight grossly beyond skeletal and physical standards as the result of an excessive accumulation of FATS in the body. Depending on age, sex, and genetic background, a BODY MASS INDEX (BMI) greater than 30.0 can be considered obese, and a BMI greater than 40.0 can be considered morbidly obese (MORBID OBESITY). Having a high amount of body fat. A person is considered obese if they have a body mass index (BMI) of 30 or more. 278.0 is a non-specific code that cannot be used to specify a diagnosis
ICD-9-CM Diagnosis 278.00
Body weight grossly beyond skeletal and physical standards as the result of an excessive accumulation of FATS in the body. Depending on age, sex, and genetic background, a BODY MASS INDEX (BMI) greater than 30.0 can be considered obese, and a BMI greater than 40.0 can be considered morbidly obese (MORBID OBESITY). Having a high amount of body fat. A person is considered obese if they have a body mass index (BMI) of 30 or more. 278.00 is a specific code that can be used to specify a diagnosis 278.00 contains 4 index entries
ICD-9-CM Diagnosis 278.01
Morbid obesity The condition of weighing two, three, or more times the ideal weight, so called because it is associated with many serious and life-threatening disorders. 278.01 is a specific code that can be used to specify a diagnosis 278.01 contains 3 index entries
ICD-9-CM Diagnosis 278.02
Overweight 278.02 is a specific code that can be used to specify a diagnosis 278.02 contains 7 index entries
ICD-10 E66 Obesity
Excludes: adiposogenital dystrophy ( E23.6 ) lipomatosis: · NOS ( E88.2 ) · dolorosa [Dercum] ( E88.2 ) Prader-Willi syndrome ( Q87.1 )
E66.0 Obesity due to excess calories E66.1 Drug-induced obesity
Use additional external cause code (Chapter XX), if desired, to identify drug.
E66.2 Extreme obesity with alveolar hypoventilation
E66.8 Other obesity
E66.9 Obesity, unspecified
Simple obesity NOS
New England Journal of Medicine
Exercise, Lymphedema, and the Limb at Risk Bonnie B. Laninski, MA, PT, CLT-LANA
The Role of Exercise in Treating Lymphedema Rehab Management
Arm Elevation and Exercise Breast Cancer.org
Getting (and Staying) Aerobically Fit through Swimming Dr. Susan Harris, Phd. PT, School of Rehabilitation Sciences – UBC
Exercise and Lymphedema Breast Care Site
Challenging the Myth of Exercise-Induced Lymphedema Dr. Susan R. Harris, PhD, PT, School of Rehabilitation Sciences - UBC Abreast in the West
Light Arm Exercises That Can Help Prevent/Manage Lymphedema
Updated Jan. 20, 2012