The incidence and prevalence of overweight and obesity are increasing globally, with many developed nations struggling to reduce the rate. This, and the consequences of obesity, are often discussed in the literature at both the individual and population levels (Scottish Government, 2018; World Health Organization, 2018). Articles on lymphoedema are no different, with several published in the last year mentioning overweight and obesity as a risk factor for development of or a complicating factor in the management of the lymphoedema (Todd, 2018a; Duyur Cakit et al, 2019; Shallwani et al, 2019). Papers published in previous years highlight this point, while simultaneously describing an increased prevalence of overweight and obese individuals presenting in lymphoedema clinics and an additional level of complexity and treatment burden (from both the individual and service perspective) (Fife and Carter, 2008; Wilkins et al, 2014; Lockwood et al, 2017; Todd, 2018b). With this in mind, and an array of strategies, guidelines and management options, what should practitioners be recommending to clients? What should treatment goals look like? And what factors prevent or enable practitioners and patients in successfully incorporating weight within the lymphoedema assessment and management plan?
Through ongoing research, the author—a registered dietitian—aims to address some of these questions. This article sets the background to the research and explores the relationship between obesity and lymphoedema while considering some of the practical challenges associated with weight management.
Obesity and lymphoedema—what is the connection?
There is widespread recognition that obesity is a risk factor in the development of lymphoedema (Clinical Resource Efficiency Support Team, 2008; Mehrara and Greene, 2014; Fu et al, 2015). However, there remains a degree of uncertainty regarding the way in which obesity impacts upon the condition, and it is likely that there is more than one factor at play. Mechanisms researched to date include increased lymph production that overwhelms the lymphatic system as a result of an expanding limb, inflammation caused by excess fat destroying the lymph vessels, compressed lymphatics as a result of adiposity and decreased lymph clearance due to reduced mobility and venous insufficiency (Mehrara and Greene, 2014).
Recognising the likelihood that weight loss would have a positive affect on limb volume and lymphoedema, Shaw et al (2007a) set out to prove their hypothesis. They also sought to ascertain whether the composition of diet (i.e. fat content) would have further effect (Shaw et al, 2007b). Their work was successful in demonstrating the positive effect of weight loss, but a lack of control over the third arm of their study prevented any conclusions from being drawn regarding the relevance of dietary fats. Thus, in the absence of detailed evidence about the mechanistic action of diet, obesity and lymphoedema, there can be only a general recommendation that overweight and obese individuals with lymphoedema should lose weight.
A review of lymphoedema management guidance suggests that there is an acceptance among experts that weight management plays an important role in the treatment of lymphoedema. However, some guidance places more emphasis on this factor than others, and unlike the four cornerstones of management (physical activity, lymphatic drainage, bandaging and/or compression garments and meticulous skin care), there is little detail regarding the practical application of weight management strategies (International Lymphoedema Framework, 2006; All Wales Lymphoedema Obesity Policy Group, 2014; London Cancer Alliance, 2015). In light of this, it is right to pose the questions of whether adequate importance is placed on the role of weight management in clinical practice and whether a lack of detail over approach acts a barrier to implementation.
Why is weight loss so difficult?
At a fundamental level, weight and energy balance are as simple as energy in versus energy out. However, any healthcare practitioner who has ever tried to support a patient to lose weight, and, indeed, any individual who has ever tried to lose weight, knows that it is rarely that easy. Then, what factors impact on the two core components: energy in and energy out? The UK Government-commissioned ‘Foresight Report’ (Butland et al, 2007) found a ‘complex multifaceted system of determinants where no single influence dominates’ (p7). The report's obesity map goes on to portray a series of positive and negative feedback loops that firmly challenge the concept of individual responsibility due to the dominance of environmental, biological and economic factors (Butland et al, 2007).
While no papers in the field of lymphoedema explore obesity in such detail as the Foresight Report (Butland et al, 2007), some do urge practitioners to consider comorbidities when developing individual management plans (Fife and Carter, 2008; Todd, 2018a; 2018b). Others highlight the importance of patient activation and recognise that previous experiences of weight management services and outcomes could negatively impact upon an individual's willingness to engage in weight loss intervention (Wilkins et al, 2014; Lockwood et al, 2017). This demonstrates a level of understanding regarding the complexity of weight management; however, it does not provide conclusions regarding the effectiveness of clinical practice in managing the issue.
Despite a general acceptance that obesity is complex, it remains surrounded by stigma (Butland et al, 2007). Stigma is defined as ‘the co-occurrence of its components—labelling, stereotyping, separation, status loss and discrimination’ and for stigmatisation to occur, ‘power must be exercised’ (Link and Phelan, 2001). Weight stigma is known to have a negative impact on individuals and their health, with research reporting adverse consequences for mental health and weight loss (Puhl and Heuer, 2001; Spooner et al, 2018). Despite this, many studies have demonstrated the presence of weight stigma among healthcare professionals (Owen-Smith et al, 2018; Spooner et al, 2018). Encouragingly, research has also shown that education can reduce stigma, thereby improving the therapeutic relationship and enhancing interventions (Sanchez-Ramirez et al, 2018).
What is significant and successful weight loss?
There are a number of weight loss approaches employed by the NHS and many more available to the general population through commercial routes. A review of the literature focused on enrolment and completion rates (general engagement) shows variations by demography, complexity, recruitment method, intervention and goals (Dalle Grave et al, 2005; Jolly et al, 2010; Ahern et al, 2016), further evidencing the need for a better understanding of the impact of approach, so that outcomes associated with weight loss interventions can be maximised. However, in the absence of this, and in light of the complexity of obesity, the NHS recommends an approach that incorporates behaviour change interventions alongside dietary modification and regular physical activity. The golden thread to this approach is individual goal setting; however, evidence suggests there may be a disconnect between the views of health professionals and the views of patients when defining ‘successful’ weight loss. A 5% reduction in body weight has been shown to impact upon physical health (cardiovascular risk factors, morbidity and mortality) (Jensen et al, 2014). Thus, many practitioners encourage patients to aim for 5–10% weight loss. However, research has shown that patients' weight loss goals can average as much as a 32% reduction in body weight (Foster et al, 1997). This disconnect requires careful management to ensure that people feel empowered, supported and successful when any weight loss is achieved.
Long-term weight loss is often defined as ‘losing at least 10% of initial body weight and maintaining that loss for at least 1 year’ (Wing and Hill, 2001). It is commonly perceived that weight maintenance is elusive for most people, but evidence suggests that approximately 20% of those who attempt it are successful in long-term weight loss maintenance, and maintenance gets easier over time (Wing and Phelan, 2005). Thus, if an individual has maintained their weight loss for 2–5 years, their chances of longer-term success are greatly improved. This leads to the conclusion that the optimal duration of support and the structure of effective weight loss programmes may be 2–3 years.
Next steps
Over the next year, the author's team will conduct research on weight loss and lymphoedema management across the UK. This will include many of the themes explored here and will add to the evidence base concerning practice in lymphoedema management and obesity.
Conclusion
An improved understanding of health providers' and the public's attitudes towards obesity could have a significant impact on clinical outcomes and clinicians' ability to deliver interventions that enable supported self-management of lymphoedema. Recognition of the complex interactions that impact upon weight loss and weight maintenance and the interplay between weight and other long-term conditions, such as lymphoedema, could also have a profound effect. Research from the field of obesity will provide important insights into the long-term management of lymphoedema, although additional research focused specifically on the population with lymphoedema is vital to ensure that management strategies are optimal.
KEY POINTS
- Overweight and obesity are known risk factors for the development, and a complicating factor in the management, of lymphoedema
- Successful treatment of obesity requires full consideration of the interconnecting factors that drive the problem, many of which are out of the individual's control
- Barriers such as weight stigma must be considered and addressed among the general population and health professionals
- Weight loss of 5–10% of baseline body weight is considered clinically significant and realistic in the general overweight and obese population
CPD REFLECTIVE QUESTIONS
- How could awareness of obesity and lymphoedema lead to improved outcomes for patients?
- Think of a patient with obesity and oedema within your area of practice whose weight has been maintained or increased during the period of your intervention. Reflect on the reasons for this and your interactions. Could anything have been different and how would this have influenced outcomes?
- Reflect on the skills, knowledge and assets available to you while working with people who have obesity and lymphoedema. How could they be improved and what impact would this have on your practice, individual patients and your service?