A NEW LOOK AT LYMPHEDEMA AND OBESITY: BREAKING THE CYCLE
Part II: What Can We Do About It?
The Role of Lymphedema Therapists
by Leslyn Keith, MS, OTR/l, CLT-LANA
It has been well established in the literature, as well as in clinical practice, the profound effect that obesity has on lymphedema. Obesity places significant additional challenges for self-management of lymphedema on an already labor-intensive chronic condition. Many lymphedema clinics are experiencing the regular return of patients with obesity and lymphedema for repeated courses of treatment, often with progressively climbing weight and further exacerbation of swelling. It has become more and more evident that weight management must be included in the effective treatment of lymphedema when obesity is a co-morbidity.
Approach to Obesity in America
The typical strategy for promoting weight loss over the last thirty to forty years has been to achieve a negative energy balance by eating less, exercising more, or both. This was initially promoted pervasively through the official publication of the Dietary Goals for the United States in 1977 that resulted in the USDA Food Pyramid. Studies of the prevalence of obesity in America demonstrate that the beginnings of the obesity epidemic was in the mid-1980s7 coinciding with our government’s recommendation to eat more carbohydrates, less fat, fewer total calories, and to exercise more.13
Research suggests that the fundamental cause of obesity is not one of physics but of chemistry. Research and clinical knowledge, as early as 187211 and up until the National discourse changed in the late 1970’s, demonstrated that diets comprised of an excess of carbohydrate and devoid of fat lead to storage of excess adipose tissue, disease and early death.2, 13, 16 It is impossible for an otherwise healthy individual to become overweight on a diet comprised solely of proteins and fats, no matter how little one exercises.19 Carbohydrates in a surprisingly small excess are required for accumulation of adipose tissue and weight gain.5, 13
Ketogenic Diet for Health and Weight Loss
A ketogenic diet is a low carbohydrate, moderate protein, high fat diet that forces the body to use fat (ketones) for fuel instead of carbohydrate (glucose). A ketogenic diet promotes ketosis, a healthy metabolic state that doesn’t require the presence of insulin, allowing blood sugar to stabilize. Intake of dietary carbohydrate, a non-essential macronutrient, causes the release of insulin which immediately puts a stop to fat burning, and forces all excess carbohydrates into adipose tissue.
Despite the tendency of the medical community to falsely malign dietary fat and to encourage intake of unhealthy amounts of carbohydrate, there has been significant recent research that has again established that a well-formulated ketogenic diet is the healthier way of eating and the most successful one for weight loss. Fortunately, the paradigm is shifting in the scientific community. This is reflected in the mainstream media with a recent Time Magazine article. Any concerns regarding the consumption of a high fat diet were irrefutably dispelled with this review of literature absolving fat, including saturated fat, of its ostensible connection to health problems.15
Recent studies demonstrate healthier outcomes with a low carbohydrate, ketogenic diet even in the presence of obesity-related co-morbidities such as metabolic syndrome,14 hyperlipidemia,4 cardiovascular disease,16 and type 2 diabetes.2
A review of studies performed from 2002 to 2006 examining the efficacy of a well-formulated low-carbohydrate ketogenic diet have demonstrated superiority in all markers of good health including reduction of weight, percent body fat and BMI as well as blood chemistry improvements, such as lowered triglyceride and blood glucose levels, increased HDL, and improved insulin sensitivity.16 This is accomplished without restricting calories or discouraging dietary fat intake, and without muscle wasting which is commonly observed in low fat, calorically-restricted diets.
Because of its proven effectiveness in the treatment of obesity, a well-formulated low-carbohydrate ketogenic diet has particular implications for the treatment of obesity when lymph stasis is also present. Chakraborty et al.3 demonstrated in their research that dietary lipid intake resulted in increased lymph flow whereas ingestion of a high fructose diet resulted in decreased frequency of lymph contraction and lower vessel tone. Further, some researchers believe that insulin resistance, a precursor to type 2 diabetes and associated with diets high in carbohydrates, increases lymphatic load.8
Group-based Lifestyle Modification
Although a low-carbohydrate ketogenic diet has been demonstrated to be effective in the treatment of obesity, many factors prevent patients from changing their behavior and adhering to a life-long weight management program. Many of our patients find it difficult to change, even when faced with a potentially fatal health condition. Studies examining the effectiveness of intervention groups that promote lifestyle change for obese participants have shown these groups to be the best approach.1, 6, 12 However, research studies on the effectiveness of a low-carbohydrate ketogenic diet have used group intervention to support lifestyle change only minimally.2, 4, 19, 14 This may make it difficult to sustain necessary changes, particularly in the face of eating patterns that are outside of the norm and may even be against mainstream medical advice.
In all of the weight loss group intervention studies reviewed, only one included an intervention group using a low carbohydrate diet,9 and this was the only group-based intervention study in which participants improved in blood markers, such as triglycerides, cholesterol and blood glucose levels. This only occurred for the first twelve weeks, at which time, the low-carbohydrate group was allowed to increase their carbohydrate intake, until gradually there was no difference in outcome measures between intervention groups. For this reason, the researchers in this study concluded, erroneously in my opinion, that weight loss and overall health improvement will occur regardless of diet as long as behavioral support and lifestyle modification is part of the program. The homogeneity of dietary recommendations (high carbohydrate, low fat) in studies examining the best approach for promoting and sustaining health behaviors for obese participants, however, makes the superiority of group intervention to provide support, education and an increased sense of self-efficacy more evident. Not surprising though, was the high attrition rate in these studies because of the starvation diet and an accompanying directive to exercise more.
An Evidence-based Program
I propose combining the best evidence-based intervention approaches and strategies to help our obese patients with lymphedema reduce and manage their weight. To further study this, I will be developing and implementing a lifestyle modification group as partial fulfillment of requirements for my clinical doctorate in occupational therapy. I am using two existing programs as models for my program: The Duke Lifestyle Medicine Clinic in Durham, NC and the USC Lifestyle Redesign(R) Weight Management Program.
Eric Westman, MD, MHS is the director of the Duke Lifestyle Medicine Clinic and bases his program on a well-formulated low-carbohydrate ketogenic diet individualized for his patients. The clinic offers a group orientation class, regular one-on-one visits with Dr. Westman and monthly informal support group meetings at a local restaurant. Dr. Westman has authored many peer reviewed articles, several books and has participated in several research studies regarding the ketogenic diet. He is the current president of the American Society of Bariatric Physicians and is one of very few physicians who is board certified in obesity medicine.
The USC Lifestyle Redesign(R) Weight Management Program is based on the concept of Lifestyle Redesign(R) that was validated with the USC Well Elderly Research Study performed 1994-1997 in Los Angeles, California. Didactic learning, group experience and personal reflection facilitated by an occupational therapist was found to have a profound effect on the participants in the study.10 The current 16-week Weight Management Program at USC uses the proven concepts of Lifestyle Redesign(R), but the dietary recommendations adhere strictly to conventional nutritional advice (high-carbohydrate, low fat).
My proposed program for individuals with lymphedema and obesity will be a 12-week course comprised of both group as well as individual treatment sessions. Group sessions will consist of didactic and experiential learning, group activities, community outings, and online support. Meeting topics could include nutrition, meal planning, grocery shopping, health risks of obesity, impact of obesity on lymphedema, physical activity, time management, importance of sleep, stress management, problem-solving and coping strategies. Community experts who will be consulted or will present to the group may include certified diabetes educator, specialist in thyroid disorders, physical therapist, hypnotist, dietician, or a bariatric physician. On-going long-term support through a participant-led support group would be available. The goals of the program are threefold: improved health and more effective management of lymphedema, increased self-efficacy through education and support, and sustained lifestyle change.
My goal is to develop an easily replicable program that can be used in other lymphedema therapy clinics that are experiencing similar rises in their obese patient population. Both physical therapy and occupational therapy have group billing codes, but insurance reimbursement may not be necessary for sustainability of this program. Many people who have fought their weight for a long time are used to paying cash for a weight loss program. Start-up costs may be minimal in a facility that already has accommodations for group meetings and a bariatric population. Participant monitoring can be accomplished with a body composition scale and regular blood panels to assess glucose, insulin, lipid and thyroid levels. Teaming up with other health professionals, using principles of motivational interviewing, and accessing other resources in the community can make this program very successful.
Many of our patients who are obese with lymphedema have been struggling with their condition and other multiple co-morbidities for a long time, some of them for most of their life. They often relate to us their sense of hopelessness after a lifetime of failed diets. They have been ridiculed, belittled, and treated as second class citizens. How many have simply given up, have decided not to leave home, and are not even seen in our clinics? The conventional medical advice to eat less and move more has failed for over a generation of Americans and now we have an ever rising population of people suffering with obesity. It’s time for a paradigm shift in how we think about fat. It’s time to be a leader, challenge the status quo and stand up for our patients. It’s time to break the cycle of lymphedema and obesity by embracing the science.
1. Ash, S., Reeves, M., Bauer, J., Dover, T., Vivanti, A., Leong, C., O’Moore Sullivan, T., & Capra, S. (2006). A randomised control trial comparing lifestyle groups, individual counselling and written information in the management of weight and health outcomes over 12 months. International Journal of Obesity, 30, 1557-1564. doi:10.1038/sj.ijo.0803263
2. Boden, G., Sargrad, K., Homko, C., Mozzoli, M., & Stein, P. T. (2005). Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with Type 2 Diabetes. Annals of Internal Medicine, 142(6), 403-411.
3. Chakraborty, S., Zawieja, S., Wang, W., Zawieja, D. C., & Muthuchamy (2010). Lymphatic system acts as a vital link between metabolic syndrome and inflammation. Annals of the New York Academy of Sciences, 1207(Suppl 1), E94-102. doi:10.1111/j.1749-6632.2010.05752.x.
4. Dashti, H. M., Al-Zaid, N. S., Mathew, T. C., Al-Mousawi, M., Talib, H., Asfar, S. K., & Behbahani, A. I. (2006). Long term effects of ketogenic diet in obese subjects with high cholesterol level. Molecular and Cellular Biochemistry, 286, 1-9. doi:10.1007/s11010-005-9001-x
5. Davis, W. (2011). Wheat Belly. New York, New York: Rodale Press.
6. Digenio, A. G., Mancuso, J. P., Gerber, R. A., & Dvorak, R. V. (2009). Comparison of methods for delivering a lifestyle modification program for obese patients. Annals of Internal Medicine, 150(4), 255-262.
7. Finkelstein, E. A., Strombotne, K. L. & Popkin, B. M. (2010). The costs of obesity and implications for policymakers. Choices: The Magazine of Food, Farm & Resource Issues, 25(3).
8. Foeldi, E. (personal communication on June 19, 2013)
9. Foster, G. D., Wyatt, H. R., Hill, J. O., Makris, A., P., Rosenbaum, D., L., Brill, C., Klein, S. (2010). Weight and metabolic outcomes after 2 years on a low carbohydrate-versus low-fat diet: A randomized trial. Annals of Internal Medicine, 153, 147-157.
10. Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: The well elderly study occupational therapy program. American Journal of Occupational Therapy, 52(5), 326-336.
11. Pennington, A. W. (1953). Treatment of obesity with calorically unrestricted diets. The Journal of Clinical Nutrition, 1(5), 343-348.
12. Riebe, D., Blissmer, B., Greene, G., Caldwell, M., Ruggiero, L., Stillwell, K. M., & Nigg, C. R. (2005). Long term maintenance of exercise and healthy eating behaviors in overweight adults. Preventive Medicine, 40, 769-778. doi:10.1016/j.ypmed.2004.09.023
13. Taubes G. (2011). Good calories, bad calories. New York, New York: Random House.
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15. Walsh, B. (2014). Ending the war on fat. Time Magazine, 183(24).
16. Westman, E. C., Yancy, W. S., Edman, J. S., Tomlin, K. F., & Perkins, C. E. (2002). Effect of 6-month’s adherence to a very low carbohydrate diet program. American Journal of Medicine, 113, 30-36.
17. Westman, E. C., Feinman, R. D., Mavropoulos, J. C., Vernon, M. C., Volek, J. S., Wortman, J. A., Phinney, S. D. (2007). Low-carbohydrate nutrition and metabolism. American Journal of Clinical Nutrition, 86, 276-284.
18. Westman, E. C. & Steelman, G. M. (Eds.). (2010). Obesity: Evaluation and treatment essentials. New York, New York: Informa Healthcare.
19. Yancy, W. S., Olsen, K., Guyton, J. R., Bakst, R. & Westman, E. C. (2004). A low carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia. Annals of Internal Medicine, 140(10), 769-777.