Episode #361: Lipedema

19:27Dr. Jordan Feigenbaum:I mean effectively you have destruction of tissue that's going unchecked here, and yeah, generally that causes bad things to happen, particularly in this case pain. Yeah, it's funny that individuals with lipoedema, when you kind of look at their inflammatory profile, I know that's kind of like a meaningless phrase. You're like, what the heck are you talking about? Like just the levels of inflammation or if you took a biopsy of their tissue, can you see evidence of inflammation? Well, you sure do. Pretty much like you could sample the area of the legs. You're going to see more inflammatory infiltrate, immune system function, all that stuff going on.

20:01Dr. Jordan Feigenbaum:If you take a blood sample, you're going to see higher rates of inflammation. And so the pain that people are experiencing, it's not just related to like, oh, you got this inflammation, you got this tissue damage, but it's certainly contributing. It's a biological sort of driver of that pain experience, which can obviously vary amongst individuals. And you add to that some mental health sort of stuff going on and decreased sort of activity levels due to some limited mobility due to the legs being larger. And yeah, the pain sensitivity being greater is kind of an expected response there.

20:38Dr. Austin Baraki:Yeah, we know that inflammation in general, either local inflammation or systemic inflammation has an effect to basically sensitize the nociceptors or the nerve endings that facilitate or are part of the biological pathway for the experience of pain. There's a lot of other modifiers up the chain that can alter people's experience, either kind of dampening it down or amplifying it up. and you've alluded to a few of them. I was trying to think about whether there's some sort of analogous condition of another tissue type here in the body. And it's not a perfect one, but I'm trying to convey the concept of how this genetic susceptibility lays down the increased risk such that when overall fat stores expand, they get expanded in a really pathological way that leads to problems.

21:24Dr. Austin Baraki:And one, again, not a perfect one, but came to mind is people with the myostatin mutations. I was literally thinking that. Yeah, we're both thinking of the same thing. You have a gene that upon increasing body mass will lead to kind of this pathological or abnormal laying down of muscle tissue that in that condition is not necessarily inherently painful. So that's one distinct aspect. But it is dysfunctional. It does not function as healthy, quote unquote, normal muscle does. and even you know among those without this condition there is a role for quote-unquote healthy normal amounts of body fat there's an important role that that plays we know that from from other conditions for example like extreme starvation experiments and people with lipodystrophy who cannot lay down enough body fat they have tons of problems and incidentally enough develop diabetes immediately because they have no storage site for excess energy and so there is an important role for, you know, physiologically healthy amounts and functioning of both muscle and body fat and that genetic predisposition leading to when that compartment expands, you get dysfunctional muscle that doesn't work properly.

22:34Dr. Austin Baraki:Here you get dysfunctional body fat that doesn't work properly. And incidentally, in the setting of the inflammation affecting, you know, nervous system function and the impact on pain experience leads to that as an additional component. So trying to draw an analogy to help people understand, like, what do you mean when you say this is genetic, yet it kind of manifests, it's more likely to manifest when people gain weight. How is that different than common obesity? And that's kind of the analogy that came to mind to illustrate that.

22:59Dr. Jordan Feigenbaum:Yeah, you have cells that are primed to function abnormally, meaning they're going to grow and enumerate themselves, otherwise wouldn't happen as readily, and they're in a particular area. And then you get that sort of environmental trigger, in this case, weight gain that tends to set the whole thing off. Although not in all, folks. Not in everyone. Yeah. Yeah. But the majority of the time. All right. Well, let's move on to diagnosis. So how is lipoedema diagnosed? Well, this is a clinical diagnosis, which basically means that your doctor just makes it up.

23:30Dr. Austin Baraki:Yeah. Very common phrase to call something a clinical diagnosis, which for a long time I've held as a kind of a silly phrase. And there's actually a well-known paper among internal medicine nerds that something to the effect of like clinical diagnosis, like, isn't that all of them basically that you're talking to? But the point is that there's not like a single simple lab test that you can check that'll cleanse the diagnosis. You have to pull together different clues and different pieces of information to get there.

23:55Dr. Jordan Feigenbaum:Yeah. And importantly, it's really a diagnosis of exclusion. So for example, you need to rule out other sort of like organ dysfunction that could cause edema. We talked about a few of those at the beginning. So cardiogenic, so stuff from the heart, stuff from the liver, stuff from the kidney. You need to rule out lymphedema, which would be another reason why the lower extremities would be swollen. Although, again, you wouldn't expect pain, but not everybody's diagnosis reads the textbook, and so things can be different. But, yeah, it's a clinical diagnosis of exclusion. There's not like a blood test, a genetic test, an image that you can take that's going to be like definitively it is this.

24:29Dr. Jordan Feigenbaum:You've got to pull together information from all different places, make the diagnosis, and, again, rule out other stuff that could cause the same sort of clinical presentation but is not lipedema. But again, the two criteria that we're really focusing here on are the disproportionate, symmetrical increase in adipose tissue, fat tissue on both legs, spares the feet, and it's associated with pain in these affected areas. There's another thought based on the latest guidelines to recommend also using this International Classification of Functioning Disability and Health Survey. It's called abbreviated ICF.

25:07Dr. Jordan Feigenbaum:This is a survey-based tool that kind of assesses somebody's quality of life, their health profile, so it can be useful to kind of track and monitor things over time. You can use some additional imaging, right? So lymphoscintigraphy, this can be used for patients with an elevated BMI greater than 30, basically looks at your lymphatic system's function. So just to make sure it's not lymphedema, for example. You can also have lipolymphedema, where you have both lipoedema and lymphedema together. That happens. And so, yeah, there's not really a role in that for diagnosis, but again, to rule out, oh, this is lymphedema.

25:50Dr. Austin Baraki:Yeah, that's a not very commonly performed imaging test. I think I've ordered two lymphocentigraphies in my career to date on patients who had unique situations that needed to differentiate, hey, where are the lymphatics going wrong? It was not as part of a diagnostic evaluation for lipedema.

26:05Dr. Jordan Feigenbaum:Yeah. Yeah. MRIs have also been performed usually preoperatively for some planning. But again, just to make sure there's not anything else going on. Not a surgeon, but I would imagine you wouldn't want to cut into an area without some pictures of what you're doing.

26:20Dr. Austin Baraki:Yeah. Most often useful for surgical planning. Also, if you're just not confident in your diagnosis, getting better characterization can be useful for that and to make sure you're not cutting into something you shouldn't be or something that's not going to respond to your scalpel. Yeah. There you go.

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32:11Dr. Jordan Feigenbaum:Let's talk now about how to treat lipoedema. And we're going to use a multi-pronged interdisciplinary is the buzzword approach here, starting with some lifestyle modifications. And I am happy to report that the latest guidelines on this really make a strong push towards exercise. They are, I mean, look, if Barbell Medicine is the number one, like, promoter of exercise in the medical space, these people may be number two. Like, if I met them, I would definitely buy them a beer. Yeah, I'm very impressed. And the main role here of exercise is not really from like a weight management standpoint. And they go through extensive detail and painstaking sort of text to say, look, we're not trying to get people to really lose weight via exercise, but rather to improve their function.

33:02Dr. Jordan Feigenbaum:Because one of the big issues here with lipoedema is that due to the pain and due to the enlargement of the limbs, their mobility tends to suffer. So their function goes down, their quality of life goes down. And oh, by the way, that makes the condition worse because you get more inflammation, more necrosis of that fat tissue, more fibrosis, all generally bad things. So their big push here is get people active, get people exercising. Yeah, there may be some knock-on effect on weight control and insulin sensitivity and certainly a number of other health benefits. But with respect to lipoedema, it tends to decrease the inflammation in the excess adipose tissue and tends to improve their function because they're doing so – they're basically practicing moving and exercise.

33:49Dr. Jordan Feigenbaum:And there's going to be some exercise-induced sort of analgesia, some sort of pain reduction. So what's the recommendation here? It's the same as the current physical activity guidelines. They should lift weights. They should do conditioning. I kind of view any sort of specific considerations around exercise to be very similar to other conditions that are associated with limited mobility. So, for example, like COPD, right? Obviously, these are two distinctly different diagnoses and different sort of symptoms. But individuals with COPD have limited capacity to participate in traditional conditioning.

34:24Dr. Jordan Feigenbaum:They start breathing too hard or whatever. And so you're like, well, they still need to exercise. So what do? Intervals. tend, you know, that's been tested in COPD folks. They tend to tolerate them better and get good benefits from that. Resistance training seems to be preferred by these individuals. And so I kind of favor something like that, but without the specifics, because I do think that each particular individual is going to have their own specific things. Like I feel comfortable doing this. I'm able to participate in this, but these other things are more challenged. I feel like I can't actually work out.

34:53Dr. Jordan Feigenbaum:And oh, by the way, they make me feel not so great. And so I think it's just going to be individualized, which kind of takes us back to our general sentiment regarding like, what sort of considerations do I need to make around this particular medical condition? It's like, well, there are none specific to the medical condition. It's more specific to the individual, which you were going to do anyway, right? Right. Yes.

35:14Dr. Austin Baraki:Yeah. This is such a common, common thing that I wish we could, um, I don't know how we get more people to grasp the concept is that the, the diagnostic label in the, in most situations, uh, is not the predominant driver of specific exercise-related modifications. There are certainly some where that becomes necessary, but way, way, way more often, if you do a good job assessing the person's current capacity, their goals, their tolerance, their equipment, their preferences, you will be able to get a long way, even if you didn't know about their medical condition. Again, not in every case. There are certainly some situations you have some sort of advanced congenital cardiomyopathy, or you have severe advanced muscular dystrophy or certain other things where it's like, nah, that's gonna like certainly guide my decision-making pretty hard.

36:02Dr. Austin Baraki:But those are certainly a minority of situations, whereas just getting a sense of like, hey, where's the person at? What can they tolerate? And where are we trying to get? You can get a long way whether or not you actually explicitly modify variables because of just the presence or absence of a diagnostic label on their medical chart.

36:17Dr. Jordan Feigenbaum:Yep, yeah, exactly. So TLDR, exercise promotion, wow. Yeah.

36:22Dr. Austin Baraki:Shocking, shocking development on the Barbell Medicine podcast. There you go, yeah.

36:27Dr. Jordan Feigenbaum:Equally shocking is the recommendation by the current guidelines and our corroboration that individuals with lipoedema should be recommended and counseled and supported to adopt a health-promoting dietary pattern. Now, some of this is related to weight management, which we'll discuss in a little more detail in about 120 seconds. But there are also additional non-weight-related health benefits of just changing the dietary pattern. That's a lot of other chronic medical conditions that individuals are likely to have. So high blood pressure, for example, would be one. Insulin resistance, for example.

37:04Dr. Jordan Feigenbaum:Sure, weight loss does tend to help in addition to the just adoption of a health-promoting dietary pattern, but the diet itself also tends to improve those sort of things. And so if you can get individuals to move towards a more minimally processed or unprocessed dietary pattern that has the correct amount of energy to support not only physical activity but also a healthy body composition and body weight, and they can adhere to that, likely requiring some modification of their food environment, their cooking skills, the foods they shop for, et cetera, all of that, evergreen will be recommended for everyone.

37:40Dr. Jordan Feigenbaum:So no surprise that it's recommended here. But I did want to point out that these guidelines, which again, all this stuff is linked in the show notes below, they take, again, special care to recommend against any sort of like short-term diet, short-term rapid weight loss kind of diet. Because one of their contentions that I think is, it feels, again, truthy, is that the association of lipoedema with obesity has really kind of hamstrung the discussion of not only that pathophysiology behind lipoedema, but also its management. Because the recommendation is that, oh, just lose weight. Just do that.

38:16Dr. Jordan Feigenbaum:And, you know, unfortunately, lifestyle alone, that's diet, exercise, sleep, et cetera. Now that it has no effect on weight management, just that the effect tends to be relatively modest in most folks. And the majority of folks are not going to be able to lose a sufficient amount of weight to adequately get them to a, quote, you know, a healthy body composition, healthy body weight. And so their thought is like, look, the recommendation, follow this diet or whatever. people just yo-yo and then end up gaining more weight than where they were in the first place, which would worsen lipoedema in these folks.

38:52Dr. Jordan Feigenbaum:Yeah.

38:53Dr. Austin Baraki:Yeah. Little to add, I agree. I think this

38:55Dr. Jordan Feigenbaum:requires careful discussion and recognition. Yeah. Well, as long as we're talking about weight management, let's keep it going. Weight stability is important here because gaining weight would increase not only the risk of somebody who's got this sort of painless lipohypertrophy developing into lipoedema, but also weight gain in an individual with lipoedema makes the symptoms worse, generally speaking. And, you know, while some have argued that the fat in the legs in folks with lipoedema is not the same as stored fat in obesity, which suggests that it could not be, you know, lost through diet, exercise, or other methods of weight loss.

39:27Dr. Jordan Feigenbaum:This is not, that's not an evidence-based take. I mean, I've seen even this just this week, and I don't know if my phone's listening to me or whatever, but on my explore page, it's, you know, people just talking about lipoedema and say, yeah, it doesn't respond to exercise and diet. I'm like, well, that's kind of true if you say that exercise and diet doesn't really cause weight loss. Although I would say that exercise tends to reduce the symptoms based on existing evidence. So that kind of an issue there. But yeah, it's not that this is some sort of special top secret locked in fat that just doesn't respond to weight loss.

39:58Dr. Jordan Feigenbaum:And so surgery is the only option. That's definitively not the case. You look at reams and reams of evidence, weight loss tends to promote loss of fat mass in the lower extremities. And the best data we have on this is from metabolic bariatric surgery, mainly because the folks lose so much weight that if there was this sort of disproportionate retention in fat. So imagine a person, they went underwent metabolic bariatric surgery and they lost a hundred pounds. They lost nothing from their legs though. You'd be like, dang, this fat, it is unresponsive to any sort of traditional type of weight management.

40:33Dr. Jordan Feigenbaum:But that is not the case. You see a proportional loss in body fat in the lower extremities.

40:37Dr. Austin Baraki:Yeah, it reminds me again to draw some analogies from other areas. Also like the concept of it doesn't quote unquote respond. What exactly are we referring to and how are we measuring response, right? So there's like the pain element. There's the actual amount, size, potentially how that impacts the kind of cosmetic appearance of the legs. There's the inflammatory aspect, things like that. And so an analogy that I'm thinking of here is in the context of fatty liver disease. And that's a situation where there is kind of similar dysfunctional fat that is infiltrating the liver, leading potentially to inflammation, to fibrosis, to scarring.

41:13Dr. Austin Baraki:A lot of that is similar to what's described in the fat mass in lipedema, where there's this inflammation and fibrosis that's happening. And in fatty liver disease, we know that there are certain thresholds of body weight loss thresholds, for example, to lead to certain outcomes. So if we want to, you know, improve the inflammation, if we want to improve the fibrosis, if we want to, you know, mitigate the risk, we can't reverse cirrhosis, but mitigate the risk of cirrhosis most significantly, there are certain thresholds of, do you need 5 % body weight loss for this, 7.5 % for this, 10 or 15 % weight loss to achieve this particular outcome.

41:46Dr. Austin Baraki:And so here, similarly, it might be a kind of a similar almost threshold based model where through traditional quote unquote diet and exercise, you know, it's actually quite challenging for a lot of people to lose a lot of body fat and sustain that weight loss. And so does that mean that in common, what we'll call common obesity, regular body fat doesn't respond to diet and exercise or is it more a threshold type effect? Well, when we induce greater degrees of weight loss, for example, using anti-obesity medications, we get 18, 20, 22 percent body weight loss from somebody. On some of our modern GLP-1s, we see a much more potent response in terms of fat loss and improvements in inflammation and various other issues.

42:29Dr. Austin Baraki:And then as you're pointing out, when we have metabolic bariatric surgery, 22, 25, 30 percent body weight loss, we similarly see that as well. So I'm curious how much of it is thought, even though this fat tissue is distinct and unique from what we'll call physiologically healthy, quote-unquote, normal body fat, the idea that it would stubbornly refuse to respond to any degree of weight loss clearly appears to not be the case in most situations if a certain sufficient threshold is reached.

42:58Dr. Jordan Feigenbaum:Yep, agreed. There may be a role upcoming for pharmacotherapy-related options. Now, obviously, people are familiar with semaglutide, so we go v. ozempic, but terzepatide, so ZEP bound, for example, might actually have a little bit greater role to play. There's not data here, you know, not randomized controlled trials on this. But the mechanisms are certainly interesting. So let's talk about those for a second. Yeah, sure, terzepatide seems to be a little bit more potent with respect to its effect on weight loss. secondary to like appetite, satiety, feelings of fullness, modulation compared to like semaglutide.

43:38Dr. Jordan Feigenbaum:That seems to be, you know, pretty much true. But there's also been this sort of knock-on effect from terzepatide that it has reduces the inflammation in adipose tissue, in fat tissue, and its dysfunction. We see that in, you know, heart failure with preserved ejection fraction. We've seen that in, you know, non-alcoholic fatty liver disease, now known as metabolic associated steatosis. uh, also PCOS. Um, so that might be useful in a condition where somebody has adipose tissue inflammation and dysfunction like lipoedema. Um, so yeah, there's some interesting maybe mechanisms here. Uh, we'll see.

44:16Dr. Jordan Feigenbaum:I don't know. I don't feel confident saying there's hepatitis going to benefit lipoedema through these other sort of functions, but it could be useful for weight loss and a person who's not a good candidate for whatever reason for metabolic bariatric surgery.

44:28Dr. Austin Baraki:Yeah, super interesting. I'm very interested to see. I was, you know, before we recorded this, I was kind of searching around because, as you mentioned, it's kind of an evidence or data-free zone right now. All we have is a lot of people's kind of anecdotal experience because a lot of physicians would be comfortable trying a medicine like terzepatide in this situation. I know that I would. And seeing some pretty favorable kind of anecdotal experiences, not that we would take that to the bank as a strong evidence for conclusion, but likely, I think more likely to benefit these patients than it is to harm them.

44:58Dr. Austin Baraki:While we're on the topic of medicines, there's just a couple of the thoughts that came to mind, not only some that might help here. I'd also be curious, you know, we could look into this offline, I suppose. But medicine like pioglitazone is known as a PPAR gamma agonist, and it's one that has direct impacts on fat tissue and kind of where fat tissue tends to end up getting deposited and distributed and fat tissue differentiation and things like that. So I'd be curious if a medicine like pioglitazone has any data or research in the context of lipoedema, whether for benefit or for harm, either way.

45:33Dr. Austin Baraki:And then others would be, what medicines would be more likely to actually cause harm and should be avoided? So for example, you mentioned how there's a lot of fat tissue inflammation. And so somebody might think, oh, well, if there's a lot of inflammation, I ought to use an anti-inflammatory. So let me try some like prednisone or something like that.

45:51Dr. Jordan Feigenbaum:Yeah, blast some steroids, bro.

45:51Dr. Austin Baraki:Terrible idea. if that's what you're using it for. Now, if the patient needs prednisone for some other critically important reason, autoimmune inflammatory disease, something like that, sure. But not to treat this condition, I would expect it to probably worsen this condition. And so there's probably other medicines. You know, this is a condition where if somebody is going to be entertaining the possibility of starting a new medicine, would be probably worth looking to see, is there any evidence or reason to believe that this might worsen lipedema so that you can more accurately weigh those risks and benefits?

46:20Dr. Austin Baraki:It's not to say you shouldn't use that drug. It's just that you want to be able to accurately weigh those risks and benefits out, right? What are you potentially going to gain by trying this? And are you willing to possibly experience a worsening of this? So yeah, GLP-1s are very promising in my mind. I think they're very likely to be beneficial, but will be interesting to see better controlled trial data whenever that becomes available.

46:42Dr. Jordan Feigenbaum:Yeah, yeah. Especially in, you know, think about it. You have to get a cohort, a group of patients with lipoedema that have been diagnosed correctly. Yes. That have not been surgerized or like whatever. You know, you'll have to it'd be the recruitment issues would be challenging, but not insurmountable. Yeah, I agree. All right. So in addition to lifestyle stuff, in addition to weight management, you know, managing the rest of the symptoms becomes the major focus of like, you know, you know, why would you see your doctor? What's the what's the whole point? And starting this starts with education.

47:14Dr. Jordan Feigenbaum:So obviously, you know, this is a tricky subject to just discuss, generally speaking, because each individual is going to be different. But educating patients with lipoedema that this is a chronic condition, that it's mostly related to genetics. So it's not like some sort of, you know, moral failing, some sort of anything like that. Sounds a lot similar to just obesity, generally speaking. But I think that can be helpful, especially if that is maybe the nidus or at least a factor in their sort of maybe some mental health type stuff that's going on. And further, that this condition does respond to weight change and exercise, so weight loss and exercise.

47:50Because if someone were of the opinion that it did not, then they might be less likely to participate in those things.

47:58Dr. Jordan Feigenbaum:It's kind of like with a person who has osteoarthritis. If they've been told there's wear and tear and that, you know, you can't expose the joints to too much stress, trying to get them to exercise after that's their understanding of the condition is challenging.

48:12Dr. Austin Baraki:Yeah.

48:12Dr. Jordan Feigenbaum:So, yeah, if you – some education that's chronic condition, genetically based, responds to weight loss and exercise, generally speaking. You can use motivational interviewing to adopt the lifestyle changes, build self-efficacy through that, and also can help folks avoid unnecessary and ineffective treatments like lymphatic massage, lymphatic drainage, weird supplements because this is not a problem with the lymphatic system. If somebody does have lymphedema on top of lipedema, well, that would change. But, you know, again, making sure that person knows the diagnosis, what causes it, and some, you know, what things would modify their trajectory, I think ultimately helps them make informed decisions.

48:54Dr. Austin Baraki:Yeah, yeah.

48:55Dr. Jordan Feigenbaum:Well said. With respect to pain, because this is like one of the major symptoms used for diagnosing lipedema, compression therapy is one of the things that's consistently recommended across all guidelines on this sort of stuff. There's some thought that it may help with the inflammation, but overall, the biggest kind of driver here is that patients tend to experience less pain when they have these sort of compressive garments on, which can lead to their participation in not only formal exercise, but also just like non-exercise activity. They're just more active. So this kind of a symptom control here, which gets them to participate in gradually increasing levels, volumes, and intensities of exercise, which would ultimately also help with the pain management.

49:40Dr. Austin Baraki:Yeah, it must be. I mean, I'm curious from the patient's experience perspective, I'd be curious to hear like kind of a qualitative description of what that is like, because you mentioned how it is often described as this heavy leg feeling. If wearing some sort of compression devices maybe mitigates that aspect, so your legs feel less heavy and almost like subconsciously you're more willing and you don't even have to think about moving around quite as much compared with when they do feel heavier. That'd be interesting to hear the qualitative experience.

50:05Dr. Jordan Feigenbaum:Well, that's been reported. That type of report has been mentioned and noted a number of times in folks who spend a lot of time on their feet, right? So just their nurse, nurses, for example, like wearing compressive socks because, you know, I feel better at the end of the day. So then whatever. And if that gets somebody to be more active, to get their exercise in, 10 out of 10.

50:24Dr. Austin Baraki:But also just simple, cheap, safe intervention. Yeah, why not?

50:27Dr. Jordan Feigenbaum:We love that. But there should also be a psychosocial intervention or psychological intervention. So, again, because these mental health conditions are so prominent, now whether it's causal or just a comorbidity as a result of developing lipoedema, again, it depends on the individual. Most of the time it seems to be maybe potentially causal beforehand. But, yeah, virtually all guidelines, all consensus statements on this recommend consultation with a medical professional to focus on psychological well-being to help folks manage this chronic painful condition. And the goals here of therapy are self-acceptance, treating other mental health issues if needed because, for example, PTSD is very common in these individuals, eating disorders.

51:07Dr. Jordan Feigenbaum:Disordered eating is fairly common in this population as well. And there are self-help groups out there. Although, again, some, I guess you got to go into those things with eyes wide open because there can be some over-reliance on anecdotal sort of experiences there.

51:23Dr. Austin Baraki:Yeah. Only thing I would add, I think, especially if you're in a clinician and a patient to evaluate patients for this type of condition is to do just that, to evaluate them, not to assume that because you may have this condition that you necessarily have a lot of psychiatric issues or mental health issues or something like that. I wouldn't assume that somebody presenting with what I suspect is lipoedema has depression or anxiety or, you know, a lot of them, not them, these particular patients, but patients in general, there's a lot of conditions that have a significant psychiatric overlap or mental health kind of overlap.

51:55Dr. Austin Baraki:And I don't like when clinicians just assume that they are likely to have those conditions because it doesn't apply to everyone. And so some folks who are actually doing okay from that standpoint, they have to like go out of their way to make it clear to their doctors that that's not necessarily them. So almost like, you know, there's some, you know, certain situations where from a medical standpoint, making certain assumptions is necessary, particularly in like emergency situations. But in this type of a situation where you have the time to do the evaluation and have a conversation about things, just doing that assessment rather than assuming I think is the better advice.

52:31Dr. Jordan Feigenbaum:You mean you actually have to do the doctor thing?

52:33Dr. Austin Baraki:Yes, exactly. Okay, fair. And then the last thing I wanted to talk about was liposuction here because, again, there's some – I don't want to say misinformation because that assumes like that people are maybe doing this intentionally.

52:49Dr. Jordan Feigenbaum:I guess that would be more disinformation, but whatever. The issue here is that the data on liposuction in folks with lipoedema is challenging to interpret, mostly because there's short-term follow-up, right? So like what happens in the next three months or six months that's distinctly different than what happens in three years, six years, ten years. They use weird assessment tools that have not been validated in this patient population. And there's no like randomized controlled trial like a sham liposuction just to see like if you just pretended that somebody went under the knife. Sure. And they were wearing compressive stockings, both groups, like, so they didn't really know.

53:24Dr. Jordan Feigenbaum:So they were blinded. Would their pain symptoms decrease due to the clinical theatrics of undergoing this procedure, their expectation? I'd be curious, but we don't have that data. So that said, long-term data is generally supportive of liposuction being a good treatment, both cosmetically and also to reduce pain symptoms in folks with lipoedema, provided that they are weight stable. I'll say that again. The data is really good on liposuction as far as it reducing pain and people's cosmetic goals here if they are weight stable. The problem is that most people are not weight stable.

54:03Dr. Austin Baraki:Yeah, that seems like an important caveat.

54:05Dr. Jordan Feigenbaum:Yeah. And so the current consensus statement on this suggests that good candidates for liposuction, they would be weight stable. These are also individuals who have limited mobility due to pain and or the actual physical size of their lower extremities. They have persistent symptoms despite 12 months of conservative treatment and that their BMIs are less than 35 because if it's higher than that, it is more likely that they're having an additional or separate pathology like lymphedema, for example, which would require different sort of treatments. they also may be a better candidate for another procedure like metabolic bariatric surgery for example yeah which would have a bigger effect really than than liposuction and more permanent

54:50Dr. Austin Baraki:we think and depending on the rest of their medical evaluation you know i might also modify that bmi cutoff because we know that in recent year i think as of 2022 abms guidelines the american kind of society around metabolic bariatric surgery they dropped the usual cutoff from 35 and 40 to 30 and 35 for consideration of being eligible for metabolic bariatric surgery. So greater than 30 kind of with obesity or body fat related comorbidities. So again, it's possible for somebody to have both obesity and lipoedema, and they may have consequences of that like type two diabetes, you know, that's difficult to control or, you know, advanced osteoarthritis or other various other things.

55:33Dr. Austin Baraki:And they might actually be a great candidate, even if their BMI is a little below 35 necessarily, before their BMI exceeds 35 and they accumulate more comorbidities and medical complications of it. So that's, you know, I'm imagining if I were in this situation and entertaining the possibility of pursuing something like liposuction to address both the pain and the kind of cosmetic appearance of this issue, I'd be weighing that heavily against, even though they're obviously dramatically different procedures, but which one is more likely to impact not Not just the lipoedema, but also general health and longevity and things like that.

56:09Dr. Austin Baraki:So there's some trade-offs to consider.

56:11Dr. Jordan Feigenbaum:Yeah. Yeah. So I think that's a good summary here of lipoedema. Just to reiterate, this is a chronic medical condition we think has its origins in a genetic sort of predisposition to this condition. It is a symmetrical bilateral increase in adipose tissue, fat tissue in both legs, spares the feet most of the time, mostly occurring in women. It is responsive to both weight loss through if it's lifestyle alone, if it's metabolic bariatric surgery, so that combined with pharmaceutical interventions and also exercise seems to be beneficial. There are other therapies that are recommended, including compressive therapy, psychosocial or psychological sort of support and evaluation.

56:54Dr. Jordan Feigenbaum:Liposuction may be a reasonable treatment depending on the patient and the preferences and other factors affecting them. but overall, I just find this to be a very challenging sort of condition, not only for diagnosis, but also management. And I think I don't have a good explanation for why it's so challenging other than it's just like people just not care, you know?

57:15Dr. Austin Baraki:Yeah. I mean, I think poor recognition leads to insufficient awareness, even among clinicians, which that's the kind of thing that also will contribute to incentives towards research and things like that. So it's also under-researched heavily. So, you know, that's a tough deal. You think RFK Jr. cares a lot about lipoedema?

57:33Dr. Jordan Feigenbaum:I do not think he cares a lot about this condition. I agree. Because he would probably view it as just a willpower thing. So just, you know, let's focus on willpower. We'll save that for our political podcast, Barbell Politics. No, thank you so much to Dr. Austin Baraki for joining us here on the Barbell Medicine podcast where we talked about lipoedema. Before you guys go anywhere, please leave us a five-star rating and a review. It really helps drive traffic to our podcast. so we can keep bringing you all the latest nuance in health and fitness. From everyone here at Barbell Medicine, I'm Dr.

58:01Dr. Jordan Feigenbaum:Jordan Flagenbaum. We'll catch you next week and every week right here on the Barbell Medicine Podcast.