"Dear Body… I will remember that I am not only a patient. I am your witness. I am your advocate, and I am your partner." —Donna Piper
In this episode of the Dear Body Book Club, Donna explores Chapter Two of the new medical textbook Lipedema: Principles and Practice of Diagnosis and Treatment, edited by Stanley G. Rockson, MD; Leslyn Keith, OTD; and Catherine Seo, PhD. "Chapter Two, Addressing Lipedema: Challenges to the Primary Care Physician," was written by Matthew Carmody, MD. This chapter looks at seven major challenges primary care providers face when diagnosing and caring for people with lipedema. But it also asks something bigger: What would healthcare look like if the patient's lived experience were treated as a form of expertise? Donna translates the chapter's clinical language into everyday conversation and explores what compassionate, collaborative lipedema care can look like—from differential diagnosis and physical examination to pain, weight stigma, treatment planning, mental health support, and multidisciplinary referrals.
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IN THIS EPISODE We discuss: - Why lipedema may be missed or diagnosed as obesity or lymphedema - How lipedema, obesity, and lymphedema can occur together - Why each condition still needs to be recognized and treated separately - Why BMI alone does not provide a complete clinical picture - How body-fat distribution and waist-to-height ratio can offer additional information - Why coping with chronic symptoms may cause patients to underreport their pain - The value of asking a patient to describe a typical day in her life - How lipedema can affect pain, fatigue, heaviness, movement, sleep, social life, and quality of life - A plain-language explanation of what may be happening inside lipedema tissue - Why the patient is an important co-expert in her own care - What a respectful, collaborative lipedema examination can look like - Why treatment goals need to be individualized - The role of office staff, follow-up systems, and care coordination - The psychological effects of lipedema and repeated medical dismissal - Weight stigma, internalized anti-fat bias, and healthcare avoidance - Why primary care physicians are important in coordinating multidisciplinary care - Possible referrals for compression, MLD, CDT, movement, nutrition, mental health support, weight management, vascular care, and surgery - Why sustainable, patient-specific changes are more realistic than an overwhelming list of new rules
THE SEVEN CHALLENGES PRESENTED IN CHAPTER TWO 1. Differentiating lipedema from—and identifying it alongside—obesity, lymphedema, and other co-occurring conditions 2. Understanding the patient's lived experience 3. Defining and explaining the pathophysiology of lipedema to patients and healthcare colleagues 4. Transforming the traditional medical model into one based on patient-provider collaboration 5. Accommodating and caring for people with lipedema within a primary care practice 6. Supporting the psychological effects and addressing biases associated with lipedema 7. Coordinating care, providing resources, and making appropriate referrals
DONNA'S STICKY NOTES Sticky Note 1 Lipedema, obesity, and lymphedema can coexist—but they are not interchangeable. A patient may have one, two, or all three conditions. Each one needs to be identified so that the patient receives care for what is actually present instead of having every symptom blamed on weight.
Sticky Note 2 Coping can hide the severity of chronic illness. People who have lived with pain, heaviness, fatigue, and restricted movement for years may stop reporting those symptoms because they have learned to build their lives around them. Sometimes asking, "What is a typical day in your life like?" reveals more than asking for a number on a pain scale.
Sticky Note 3 The patient is not the least-informed person in the room. The clinician brings medical education and diagnostic knowledge. The patient brings years of experience living inside the body being examined. The best care happens when both kinds of expertise are treated with respect. KEY TAKEAWAYS - A thorough lipedema assessment involves more than weighing the patient or calculating BMI. - Lipedema can exist without obesity, and obesity can exist without lipedema. - Obesity may aggravate lipedema and may contribute to secondary lymphedema, but it should not erase the presence of lipedema. - Pain may be experienced as aching, tenderness, burning, tightness, congestion, heaviness, or discomfort with light touch. - People with lipedema may minimize their symptoms because those symptoms have become their normal. - A respectful physical examination should include explanation, consent, communication, and attention to the patient's comfort. - Treatment goals may include reducing pain and congestion, improving mobility, supporting emotional health, increasing disease knowledge, stabilizing weight when appropriate, and considering surgery when clinically indicated. - Conservative care may include compression, intermittent pneumatic compression, manual lymphatic drainage, complete decongestive therapy, water exercise, gentle movement, skincare, nutrition support, and patient education. - No medication is specifically recommended in this chapter as a treatment for lipedema itself. - The psychological burden of lipedema is not evidence that the disease is psychological. - Weight stigma is not treatment and can contribute to healthcare avoidance, distress, and poorer well-being. - Primary care physicians do not have to provide every treatment themselves, but they can help patients build and coordinate an informed care team.
CHAPTER RESOURCES The chapter includes several practical tables and resources for clinicians and patients reading along: - Table 2.1: Diagnoses associated with functional venous insufficiency leading to lymphatic failure and lymphedema — page 20 - Table 2.2: Weight-management strategies based on WHO weight-status classifications — page 21 - Table 2.3: Practical strategies for the management of lipedema — pages 24–25 - Table 2.4: Physical examination checklist for lipedema — page 27 - Figure 2.3: Understanding the pathophysiology of and interventions for lipedema — page 29 - Table 2.5: Building the office treatment care team — page 30 - Table 2.6: Roles and responsibilities of office staff in a clinical practice — page 31 - Table 2.7: Referrals to specialists for lipedema management — page 33 - Table 2.8: Referrals for diagnosis-specific interventions — page 34 - Table 2.9: Communicating general lifestyle recommendations for patients with lipedema — page 35
RESEARCH AND REFERENCES Primary chapter Carmody M. Addressing lipedema: challenges to the primary care physician. In: Rockson SG, Keith L, Seo C, editors. *Lipedema: Principles and Practice of Diagnosis and Treatment.* Springer Nature; 2026. pp. 17–36.
References cited in Chapter Two 1. Allen EV, Hines EA. Lipedema of the legs: a syndrome characterized by fat legs and orthostatic edema. *Proc Staff Meet Mayo Clin.* 1940;15(15):184–187. Available from: https://klosetraining.com/wp-content/uploads/2021/03/1940-Lipedema-of-the-Legs.pdf 2. Faerber G, Cornely M, Daubert C, Erbacher G, Fink J, Hirsch T, et al. S2k guideline lipedema. *JDDG: Journal der Deutschen Dermatologischen Gesellschaft.* 2024;22(9):1303–1315. https://doi.org/10.1111/ddg.15513 3. Sudduth CL, Greene AK. Lymphedema and obesity. *Cold Spring Harbor Perspectives in Medicine.* 2022;12(5):a041176. https://doi.org/10.1101/cshperspect.a041176 4. Herbst KL, Kahn LA, Iker E, Ehrlich C, Wright T, McHutchison L, et al. Standard of care for lipedema in the United States. *Phlebology.* 2021;36(10):779–796. https://doi.org/10.1177/02683555211015887 5. Klock S, Ziegler CG, Dischinger U. Obesity and its comorbidities, current treatment options and future perspectives: challenging bariatric surgery? *Pharmacology & Therapeutics.* 2023;251:108549. https://doi.org/10.1016/j.pharmthera.2023.108549 6. Keith L, Seo C, Wahi MM, Huggins S, Carmody M, Faerber G, et al. Proposed framework for research case definitions of lipedema. *Lymphatic Research and Biology.* 2024;22(2):93–105. https://doi.org/10.1089/lrb.2023.0062 7. Rubino F, Cummings DE, Eckel RH, Cohen RV, Wilding JPH, Brown WA, et al. Definition and diagnostic criteria of clinical obesity. *The Lancet Diabetes & Endocrinology.* 2025;13(3):221–262. https://doi.org/10.1016/S2213-8587(24)00316-4 8. Fukaya E, Kolouri R. Nonsurgical management of chronic venous insufficiency. *The New England Journal of Medicine.* 2024;391(24):2350–2359. https://doi.org/10.1056/NEJMcp2310224 9. Purnell JQ. Definitions, classification, and epidemiology of obesity. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, et al., editors. *Endotext.* South Dartmouth, MA: MDText.com, Inc.; 2000. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279167/ 10. Dudek JE, Białaszek W, Gabriel M. Quality of life, its factors, and sociodemographic characteristics of Polish women with lipedema. *BMC Women's Health.* 2021;21(1):27. https://doi.org/10.1186/s12905-021-01174-y 11. Bauer AT, von Lukowicz D, Lossagk K, Aitzetmüller M, Moog P, Cerny M, et al. New insights on lipedema: the enigmatic disease of the peripheral fat. *Plastic and Reconstructive Surgery.* 2019;144(6):1475–1484. https://doi.org/10.1097/PRS.0000000000006280 12. Dudek JE, Białaszek W, Ostaszewski P, Smidt T. Depression and appearance-related distress in functioning with lipedema. *Psychology, Health & Medicine.* 2018;23(7):846–853. https://doi.org/10.1080/13548506.2018.1459750 13. Puhl RM, Suh Y. Health consequences of weight stigma: implications for obesity prevention and treatment. *Current Obesity Reports.* 2015;4(2):182–190. https://doi.org/10.1007/s13679-015-0153-z 14. Pearl RL, Puhl RM, Lessard LM, Himmelstein MS, Foster GD. Prevalence and correlates of weight bias internalization in weight management: a multinational study. *SSM – Population Health.* 2021;13:100755. https://doi.org/10.1016/j.ssmph.2021.100755 15. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. *Journal of General Internal Medicine.* 1997;12(7):439–445. https://doi.org/10.1046/j.1525-1497.1997.00076.x
