A unique collaboration between imaging science, vascular medicine, and rehabilitation at Vanderbilt University Medical Center is transforming the diagnosis and treatment of lipedema, a debilitating and abnormal deposition of fatty tissue afflicting an estimated 17 million women in the U.S. .
The results of the study were published in the scientific journal Lymphatic Research and Biology.
Lipedema: some details on the new research
Lipedema is often mistaken for obesity, but it doesn’t respond to diet or exercise. In women, fat accumulation occurs primarily in the legs, causing them “a lot of pain and difficulty with their daily activities,” said Aaron Aday, MD, MSc, assistant professor of medicine.
“It’s a real thing,” said Aday, who specializes in vascular medicine. Yet many women “are having a horrible time trying to find a diagnosis.”
About seven years ago, Rachelle Crescenzi, Ph.D., decided to do something about it. As a postdoctoral fellow in VUMC’s Department of Radiology and Radiological Sciences, she began applying imaging techniques to improve diagnosis.
Lipoedema “had been characterized in the 1940s, but people relied on external measurements, which made it a very difficult diagnosis,” said Crescenzi, now an assistant professor in the department. With imaging, “we can look inside the body and show that this is indeed different from obesity.”
Lipedema is a disorder of the lymphatic system, which plays an important role in the removal of excess water (edema) from body tissues. Too much fluid in the heart, for example, can lead to heart failure.
Sodium (salt) plays an important role in regulating blood pressure and fluid volume. It is also a magnetic molecule and, as such, can be monitored by MRI.
Crescenzi and his colleagues developed an MRI strategy to quantify sodium content and subcutaneous adipose tissue (SAT) throughout the body. They found that sodium and SAT volumes were significantly elevated in the patients’ legs, but not in the arms, compared to women without lipedema.
In 2021 Crescenzi was awarded the first R01 (independent research grant) ever awarded for lipedema research by the National Institutes of Health. Supported by the five-year, $2.5 million grant titled “Visualizing the Vascular Mechanisms of Lipoedema,” Crescenzi established the Sodium Adipose and Lymphatics Translational (SALT) Lab, which is evaluating various treatments and diagnostic modalities.
Specifically, researchers are examining conservative physical therapy to relieve patients’ lipedema-related leg pain, weakness and excess fluids, improve mobility, and optimize their self-management program at home.
Manual techniques used in therapy include manual lymphatic drainage massage, myofascial and soft tissue releases to relax contracted muscles and surrounding connective tissues, along with the use of graduated negative pressure to expand and stretch tissues, which can improve the lymphatic circulation.
This is where Paula Donahue, PT, DPT, MBA comes in. Donahue, a certified lymphedema therapist from the Lymphology Association of North America (CLT-LANA), is an assistant professor in the Department of Physical Medicine and Rehabilitation.
Working with Crescenzi’s team, they showed that the pain relief and improvement in function experienced by women with early lipedema after physical therapy were related to a reduction in tissue sodium in the skin and SAT as measured by sodium and sodium MRI. waterfall.
This proof-of-principle study demonstrated that hands-on hand massage techniques not only helped patients feel better, but also acted directly on the source of their pain.
One of the patients “was dealing with unexplained pain and his doctor didn’t know what to do,” Donahue said. With physical therapy, “her pain went down to pretty much zero and very quickly for her… For these individuals, it has been very effective in changing their quality of life.”
“It was not thought that pathological tissue could be compressed in lipedema, that it was only fat,” added Crescenzi. “But it’s really fat and edema. We think sodium is a marker of inflammation… and it decreases after therapy.”
MRI is expensive, so Crescenzi and his colleagues are testing whether a low-cost diagnostic method, ultrasound, is just as effective at quantifying the extent of abnormal salt and SAT accumulation.
They also developed a technique called magnetic resonance lymphatic angiography to better understand the distinguishing features of lipedema. “We think the vasculature is just overloaded with a lot of edema, and it shows up on angiography,” Crescenzi said.
“We are in the early days of understanding this disease,” said Aday, co-author with Crescenzi and Donahue of the article on angiographic technique published in June in the Journal of Magnetic Resonance Imaging . “We don’t have a good mechanistic understanding of this.”
The hope is that identifying the causes of lipedema will lead to better ways to treat or prevent it.
“We can develop a national resource for lipedema,” said Crescenzi, who presented the group’s latest findings in October at the American Vein and Lymphatic Society’s Annual Meeting in New Orleans. But patients are driving the research. and pushing for a change in the treatment of lipedema. Crescenzi said: “They taught me everything”.
Dr. Sara Rucci, Nutritionist Biologist, explains how the right food approach is also fundamental: ”
The primary causes of lipedema are not yet clear, but factors are known that contribute to his developmentits progression and the onset of complications that can substantially worsen the patients’ quality of life:
abnormal growth of adipose tissue
alterations in the signaling of female sex hormones (estrogens)
alteration of the tissue drainage and vessel damage
increased local inflammation
All aspects on which the nutrition can give an important help. AND However a change of mentality is needed. We must not think of exclusively restrictive dietary approaches, which often turn out to be unsuccessful because, even when effective in terms of “weight loss”, they lead to a worsening of the disproportion between the upper and lower parts of the body, typical of lipedema. This occurs because nutritional choices do not take into account the difficulty of having to work on unhealthy and in a certain sense “inaccessible” adipose tissue.
Developing a meal plan for a patient with lipedema requires acareful customization. It is necessary to agree with the patient her goals and what she is willing to do to achieve them, evaluate any other pathologies or disorders from which she may be affected and put the strategy that she chooses to implement into her daily reality.
However, it is possible to define some common features:
Pay attention to the quality of the food: avoid preserved and industrial foods and prefer fresh and seasonal foods, meat from pasture-raised animals, caught fish and organically farmed eggs (code 0). These choices indicated for the health of the general population, become indispensable in patients with lipedema
Avoid foods rich in estrogen (soy and derivatives, meat from intensive farms, etc.) and materials capable of releasing substances that interact with the receptors of these hormones, the so-called endocrine disruptors. Remaining in the context of nutrition, avoid plastic dishes replacing them with inert materials such as glass and ceramics
Setting up a strategy that has strong anti-inflammatory action. In addition to the qualitative choices already mentioned, it will be necessary to maintain a good ratio between omega 3 and omega 6 And counteract insulin resistancea phenomenon underlying most of the ailments of our time, which plays an important role in inflammation. It must therefore be maintained low levels (and if possible very low) of simple sugars and moderate levels of complex carbohydrates, preferring proteins and good fats
There are several anti-inflammatory approaches that have proven to be useful in lipedema: the Paleo diet, the RAD diet, the modified Mediterranean diet and, last but not least, the most promising: the ketogenic diet. The ketogenic diet has the disadvantage, in my opinion, of being considered “fashionable” at the moment and for this reason often abused and not adequately tailored to patients.
In fact, it is more than a diet, a large class of diets united by the low in carbohydrates (less than 50 g or in some cases 30 g per day) and mostly hyperlipidic. It is a tool with multiple applications, very powerful if managed correctly but which can also prove harmful if applied without knowing the contraindications and precautions necessary to allow the patient to reap all the benefits.
When proposing the ketogenic diet to the patient with lipedema, it will be necessary to take into account all the elements that intervene in the onset of the pathology and which must be contrasted:
To avoid overload the lymphatic system, for which it will be necessary to choose the type of fats to be introduced, preferring those with a short and medium chain (e.g. clarified butter, coconut oil, avocado)
allow the liver to do its best work of metabolism and detoxification by introducing, for example, a good amount of cruciferous vegetables (such as broccoli and cabbage) and foods rich in omega 3 (such as oily fish and walnuts)
preserve or restoreintegrity of the intestinal mucosa and the delicate balance of the intestinal microbiota (the set of bacteria that inhabit this fundamental organ). In the latter case there are many aspects to consider. For simplicity we can say that it is good practice to introduce foods prebiotics (including fibers) and probiotics (fermented products such as yoghurt, kefir, sauerkraut, etc.) but each case must be evaluated individually.
It is very frequent that the patient with lipedema is also affected by intestinal disorders and sensitivity to certain foods, including gluten. Furthermore, the presence of hypothyroidism is particularly frequent and requires further precautions.
As we have seen, nutrition for the patient with lipedema is anything but trivial. As soon as the diagnosis is made, especially if you are lucky enough to have it when there is no overweight or obesity condition, many of the complications of the disease can be avoided.
Through a intervention custom that I like to define “tailored” you can build a diet that will help the patient get better and better trying to meet his organizational and social needs and also his preferences.
In relatively short times patients report one total pain relief and slowly observe the change in the appearance of their legs with amazement. For us professionalsachieving these goals is aimmense satisfaction above all because these are often patients who are disillusioned by previous failed therapeutic pathways and who have been living their bodies with discomfort for some time. We believe that they should be guided and supported with the delicacy that anyone who has a health problem and is looking for concrete support deserves. Their smile tells us that we are on the right track.
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