WEBVTT 00:00.111 --> 00:05.856 [SPEAKER_02]: Welcome back to the Barbell Medicine podcast where we bring modern medicine to strength conditioning and strength conditioning to modern medicine. 00:06.036 --> 00:09.239 [SPEAKER_02]: I'm your host, Dr. Jordan Faganbaum, and this episode. 00:09.979 --> 00:18.046 [SPEAKER_02]: Oh, what if I told you that there was a medical condition that is said to make folks gain fat, but not be responsive to diet and exercise? 00:18.426 --> 00:19.587 [SPEAKER_02]: Would you call me crazy? 00:20.248 --> 00:25.753 [SPEAKER_02]: Or would you say he must be talking about lipidema, chronic condition affecting many women worldwide. 00:26.213 --> 00:32.438 [SPEAKER_02]: In this podcast, we'll cover everything you need to know about light bedema, including what it is, who would affect what to do about it and more? 00:32.838 --> 00:35.840 [SPEAKER_02]: Now, on the other end of the line is the second most handsome doctor in North America. 00:35.940 --> 00:37.862 [SPEAKER_02]: Dr. Austin Baraki, what's going on dude? 00:38.462 --> 00:41.184 [SPEAKER_00]: Doing all right, looking forward to this topic. 00:41.224 --> 00:50.071 [SPEAKER_00]: I think it's one that is both important and under-recognized and might cause some folks to, I don't know, maybe reconsider how they talk about some of this stuff. 00:50.652 --> 00:50.892 [SPEAKER_02]: Yeah. 00:51.112 --> 00:51.913 [SPEAKER_02]: No, I agree. 00:51.953 --> 00:54.274 [SPEAKER_02]: I mean, there's not enough. 00:54.635 --> 01:00.218 [SPEAKER_02]: I think discussion about this coming from what should be considered like subject matter experts. 01:00.258 --> 01:04.100 [SPEAKER_02]: And I don't know if that's just a function of like, there's not that many subject matter experts out there. 01:04.140 --> 01:04.260 [SPEAKER_00]: Yeah. 01:04.461 --> 01:06.882 [SPEAKER_02]: It's just like globally underappreciated. 01:06.902 --> 01:11.145 [SPEAKER_02]: And, you know, so there's just less people out there that are like, oh, yeah, I know a lot about this. 01:11.165 --> 01:13.606 [SPEAKER_02]: I feel comfortable talking about it and it's like your legit information. 01:13.946 --> 01:14.267 [SPEAKER_02]: And so 01:15.067 --> 01:25.034 [SPEAKER_02]: It's almost, I don't want to call it a cottage industry because there has a negative connotation, but all of these like, lay groups have popped up about like, a deema with respect to, like, support what it is, whatever. 01:25.134 --> 01:34.720 [SPEAKER_02]: And unfortunately, some of the information that's been perpetuated even made its way into, you know, some sort of, some medical providers, you know, how they talk about this, it's not correct. 01:35.200 --> 01:35.540 [SPEAKER_02]: And so, 01:36.561 --> 01:37.442 [SPEAKER_02]: I don't know that it's harmful. 01:37.482 --> 01:38.702 [SPEAKER_02]: We can, you know, talk about that. 01:38.742 --> 01:39.863 [SPEAKER_02]: Maybe a philosophical discussion. 01:39.883 --> 01:41.844 [SPEAKER_02]: But yeah, we're going to talk about on this podcast. 01:41.884 --> 01:42.424 [SPEAKER_02]: So there you go. 01:42.785 --> 01:43.365 [SPEAKER_02]: Yeah. 01:43.725 --> 01:46.687 [SPEAKER_02]: Okay, before we do that, we do have two announcements. 01:46.807 --> 01:50.729 [SPEAKER_02]: One, we did just release our second generation low fatigue template. 01:50.769 --> 01:52.230 [SPEAKER_02]: It's got four different programs. 01:52.270 --> 01:55.952 [SPEAKER_02]: And it's got powerlifting programs, power building programs, general strengthening programs. 01:56.192 --> 01:57.593 [SPEAKER_02]: Previously, it's just powerlifting only. 01:57.993 --> 01:59.234 [SPEAKER_02]: The program is revised. 01:59.374 --> 02:05.358 [SPEAKER_02]: So now it's more responsive to the individual and their current training tolerance and how they're doing in training. 02:06.158 --> 02:09.201 [SPEAKER_02]: the condition work has also been updated as well. 02:09.562 --> 02:11.644 [SPEAKER_02]: And the supporting text has swell. 02:11.684 --> 02:13.086 [SPEAKER_02]: It's over a hundred and ten pages. 02:13.106 --> 02:18.271 [SPEAKER_02]: It's got a lot of information in there about programming, programming theory and like troubleshooting. 02:18.331 --> 02:18.992 [SPEAKER_02]: So all of that is good. 02:19.272 --> 02:20.393 [SPEAKER_02]: And oh, by the way, it's on sale. 02:21.054 --> 02:25.077 [SPEAKER_02]: Not just it, but all of our programs are on sale right now until August, twenty-fifth. 02:25.157 --> 02:30.781 [SPEAKER_02]: You can use code EOS, like end of summer templates, so EOS templates that check out, you're twenty percent off. 02:31.261 --> 02:31.741 [SPEAKER_02]: So there you go. 02:32.402 --> 02:43.850 [SPEAKER_02]: Also, final call, not the actual final call, but it's getting there to be the final call for our live in-person seminar, Health and Performance Seminar since San Antonio, Texas, September, twenty-th, twenty-first. 02:44.270 --> 02:46.632 [SPEAKER_02]: You can train with us the Friday before, because it's a weekend. 02:46.932 --> 02:54.258 [SPEAKER_02]: You can have dinner with us, that Saturday, and also learn everything that we know about health and health and performance and medicine. 02:54.538 --> 02:55.118 [SPEAKER_00]: Actually, good time. 02:55.338 --> 02:59.041 [SPEAKER_02]: Yeah, it's actually, no, it's a two day, if you could, an MD at the end of it. 02:59.161 --> 03:01.163 [SPEAKER_02]: It's actually, it's actually what we're giving people. 03:01.343 --> 03:01.643 [SPEAKER_02]: Yeah. 03:01.783 --> 03:08.488 [SPEAKER_02]: So that's all linked in the show notes below, also on a website, also Googleable if you, the strategy is defined. 03:08.788 --> 03:09.269 [SPEAKER_02]: Easy to find. 03:09.669 --> 03:09.989 [SPEAKER_00]: Yeah. 03:10.029 --> 03:10.550 [SPEAKER_02]: We hope anyway. 03:11.230 --> 03:13.291 [SPEAKER_02]: Any other announcements that you want to make? 03:13.931 --> 03:14.692 [SPEAKER_02]: I think that's at the moment. 03:14.832 --> 03:15.272 [SPEAKER_02]: We're doing good. 03:16.113 --> 03:28.759 [SPEAKER_02]: If you listen to the teaser on the on the our feed, it's not a barbell medicine plus subscriber and you heard me talk about Dr. Barackie's curl, you know, one single curl coming down his forehead. 03:29.119 --> 03:30.040 [SPEAKER_02]: He does not have that today. 03:30.080 --> 03:32.561 [SPEAKER_02]: I know the people were, everybody asked. 03:33.121 --> 03:34.442 [SPEAKER_02]: Oh, everyone asked. 03:36.265 --> 03:38.288 [SPEAKER_02]: the people are curious like what your hair style is. 03:38.328 --> 03:41.231 [SPEAKER_02]: So, all right, without further ado, let's get into this. 03:41.251 --> 03:44.294 [SPEAKER_02]: We're going to talk about lipidema, also called lipidema. 03:44.455 --> 03:46.177 [SPEAKER_02]: I'm going to need somebody. 03:47.649 --> 03:55.373 [SPEAKER_02]: some expert in language like to do the derivation and figure out like live edema, like bow edema, like what do we, you know what we're talking about here? 03:55.593 --> 04:02.597 [SPEAKER_00]: It's like when you look something up on Wikipedia that could mean like a bunch of different things and they have those disambiguation pages and it shows like all the different uses. 04:02.637 --> 04:13.963 [SPEAKER_00]: So there's obviously like regular edema, there's, you know, lipid accumulation, there's lymphedema, there's all sorts of variants on these terms that can cause a lot of confusion and I suspect that 04:14.603 --> 04:23.505 [SPEAKER_00]: for a lot of clinicians who are not even familiar with this condition, you would say this term and they're like, wait, do you mean regular or do you mean, are you sure you didn't mean lymphedema when you said that? 04:23.585 --> 04:26.166 [SPEAKER_00]: And so it's very, very common and in need of disambiguation. 04:27.326 --> 04:28.746 [SPEAKER_00]: Let's create the disambiguation page. 04:29.186 --> 04:29.386 [SPEAKER_02]: All right. 04:29.966 --> 04:41.489 [SPEAKER_02]: So like the demo, that's what we're going to call it is a chronic condition characterized by a disproportionate increase in fat tissue associated with pain in the lower extremities of predominantly women. 04:42.169 --> 04:45.011 [SPEAKER_02]: It rarely affects the upper extremities, but it can. 04:45.291 --> 04:53.256 [SPEAKER_02]: It also rarely affects men, but it can, particularly in some situations like liver failure or even testosterone deficiency. 04:53.296 --> 04:55.238 [SPEAKER_02]: We'll talk a little bit about that later on. 04:55.258 --> 05:04.463 [SPEAKER_02]: But again, primarily women, primarily the lower extremities, and you got to have pain and old by the way, this disproportionate increase in adipose tissue is bilateral, both sides. 05:05.164 --> 05:06.325 [SPEAKER_02]: It is circumferential. 05:06.645 --> 05:09.687 [SPEAKER_02]: So around the entirety of the lakes are not just like a nodule. 05:10.127 --> 05:11.868 [SPEAKER_02]: Uh, for example, and it spares the feet. 05:12.688 --> 05:13.229 [SPEAKER_02]: Spares the feet. 05:13.869 --> 05:19.872 [SPEAKER_02]: Um, so these are important, uh, diagnostic criteria, characterizations of this particular condition. 05:20.432 --> 05:24.154 [SPEAKER_02]: But interestingly, we made this, you know, discussion about, you know, what to call this thing? 05:24.414 --> 05:25.895 [SPEAKER_02]: Lipidema, lipidema, whatever. 05:26.095 --> 05:27.195 [SPEAKER_02]: Got a Dima in the word. 05:28.396 --> 05:39.042 [SPEAKER_02]: which is in error because there's no real edema at, you know, every time that you've seen it and it's been definitively some form of edema, regardless of the source, there's fluid there. 05:39.482 --> 05:48.547 [SPEAKER_02]: Can you just run the listeners through some additional causes of edema, or maybe some actual causes of edema, and like why that is not what this is? 05:49.168 --> 05:55.952 [SPEAKER_00]: Yeah, so clinically, you know, most of the time when we see what would be called edema, which is extremely common, it relates to 05:56.977 --> 06:05.359 [SPEAKER_00]: fluid accumulation, but that fluid is typically leaked out of the blood vessels and into this surrounding tissues, what we call the interstitial space. 06:05.519 --> 06:19.462 [SPEAKER_00]: And that can happen for a variety of reasons, if we have any like first-year med students and the audience that are going through their physiology classes, they'll learn a little bit about this in very oversimplified way, talking about, you know, starling forces and things like that. 06:19.482 --> 06:26.544 [SPEAKER_00]: But having to do with pressure, build up in the blood vessels and also other factors that relate to the tendency of fluid to be 06:27.545 --> 06:29.727 [SPEAKER_00]: retained in the vessels or the tendency of it to leak out. 06:29.907 --> 06:38.135 [SPEAKER_00]: And so once I see patients who have, for example, congestive heart failure, that is often an issue of kind of back pressure leading to a little bit of leakage of fluid. 06:38.415 --> 06:46.243 [SPEAKER_00]: Patients with cirrhosis or liver disease, they can have combinations of back pressure and a lot of these other variables that are leading fluid to leak out into spaces where it shouldn't be. 06:46.804 --> 06:49.727 [SPEAKER_00]: And certain forms of kidney disease are also quite common causes of 06:50.627 --> 06:52.388 [SPEAKER_00]: fluid accumulation like this in the tissues. 06:52.548 --> 07:03.072 [SPEAKER_00]: Other common things would be certain medicines like certain vasodilating blood pressure medicines like calcium channel blockers and gabapentin and things like that that can cause fluid leakage into the tissues. 07:03.732 --> 07:15.997 [SPEAKER_00]: And then the most common that is just generally prevalent out there is Venus insufficiency or what this similar phenomenon to when people have varicose veins, that kind of back pressure can also lead people to experience, they'll often say, hey, you know, 07:16.637 --> 07:21.959 [SPEAKER_00]: After a long day of work and being on my feet, I noticed a little bit of swelling around my ankles and it tends to go away overnight. 07:22.059 --> 07:22.999 [SPEAKER_00]: My legs are skinny again. 07:23.760 --> 07:28.421 [SPEAKER_00]: In the morning, after you've laid down and let gravity do its thing and the fluid gets reabsorbed. 07:28.781 --> 07:32.803 [SPEAKER_00]: So those are some of the most common causes of what we'll call kind of traditional edema of fluid. 07:33.243 --> 07:38.385 [SPEAKER_00]: But there are other mimics or things that can make it look swollen that are not the same type of fluid. 07:38.405 --> 07:44.987 [SPEAKER_00]: So we've alluded to one already being lymph edema, which is a different type of fluid all together from the lymphatics when that inappropriately leaks out. 07:45.747 --> 07:55.355 [SPEAKER_00]: There is lipidema, which we're talking about today, a mimic that is not fluid at all, but rather this fat tissue that can kind of visually, might initially to the uninitiated look kind of similar. 07:55.695 --> 08:02.160 [SPEAKER_00]: There's even something called mixidema, which we see in other conditions, which is neither fluid nor fat nor is it connective tissue. 08:02.220 --> 08:07.724 [SPEAKER_00]: It's this weird deposition of substances that are definitely outside the scope of what we're talking about today. 08:08.124 --> 08:12.728 [SPEAKER_00]: But they have the same ending because it might just describe a general appearance of swelling, but not 08:13.728 --> 08:18.152 [SPEAKER_00]: necessarily reflect the same underlying process or what the swelling is actually from. 08:18.292 --> 08:21.274 [SPEAKER_00]: Is it what is a kind of occupying that space? 08:21.374 --> 08:22.115 [SPEAKER_00]: Is it fluid? 08:22.135 --> 08:22.935 [SPEAKER_00]: Is solid tissue? 08:22.975 --> 08:23.436 [SPEAKER_00]: Is it fat? 08:23.536 --> 08:24.697 [SPEAKER_00]: Is it something else altogether? 08:25.097 --> 08:26.058 [SPEAKER_02]: Yeah. 08:26.298 --> 08:29.280 [SPEAKER_02]: That's a great description and great kind of rundown. 08:29.300 --> 08:38.267 [SPEAKER_02]: You know, the point is either way, if you're thinking it's a demon caused from fluid, you put an ultrasound, for example, on somebody's leg and you're trying to look like, well, how much fluid they have? 08:38.307 --> 08:38.767 [SPEAKER_02]: Where is it? 08:39.107 --> 08:48.250 [SPEAKER_02]: Yeah, you're not going to find any here in lipidema, unless they also have some other sort of underline, which is possible to two things can be true. 08:49.330 --> 09:00.573 [SPEAKER_02]: So yeah, maybe this is like a semantic kind of thing, but like if you say lipidema, which I have said for a long since I've learned about this condition for a long time, and you say it quickly, 09:02.203 --> 09:08.365 [SPEAKER_02]: Another physician or a healthcare professional might think you're saying lymphedema, but these are distinctly different entities. 09:08.545 --> 09:11.687 [SPEAKER_02]: lymphedema has fluid with lipidema does not. 09:12.427 --> 09:25.011 [SPEAKER_02]: Lymphedema is typically unilateral, one-sided, not bilateral, like lipidema, and, oh, by the way, it's painless, which is a diagnostic criteria for lipo, adema, or lipidema. 09:25.612 --> 09:28.993 [SPEAKER_02]: Again, bilateral, symmetrical both sides, and associated with pain. 09:29.693 --> 09:34.759 [SPEAKER_02]: It's also not the same thing as lipohypertrophy, which is a painless increase in adipose tissue sauce. 09:35.160 --> 09:41.287 [SPEAKER_02]: Now, lipohypertrophy can progress to lipidema, particularly in genetically susceptible women. 09:41.407 --> 09:46.232 [SPEAKER_02]: And we think that's maybe part of the pathophysiology here, but we'll talk about that later. 09:46.273 --> 09:47.454 [SPEAKER_02]: I just kind of wanted to make clear. 09:48.495 --> 10:04.971 [SPEAKER_02]: This is what Leipadema is, and this is what it isn't, because even when you go into like guidelines and various sort of, well, we consider maybe trusted resources on Leipadema like stat pearls, for example, you look on PubMed, you search Leipadema, and boom stat pearls pops up, published in twenty twenty three, like yeah. 10:05.451 --> 10:14.877 [SPEAKER_02]: Good, good resource, generally speaking, that's true, but there are extensive discussions of lymphedema in there, and you're like, what are we talking about? 10:14.997 --> 10:16.838 [SPEAKER_02]: Wrong chapter. 10:16.878 --> 10:17.438 [SPEAKER_02]: Wrong chapter. 10:17.919 --> 10:21.561 [SPEAKER_02]: Not through the fault of the authors, I think they're trying to quote disambiguate it. 10:21.761 --> 10:26.664 [SPEAKER_02]: Like you mentioned in the middle of this article, but like I could see that being missed if you were standing. 10:28.225 --> 10:29.686 [SPEAKER_02]: All right, so let's move on here. 10:29.866 --> 10:31.827 [SPEAKER_02]: What are these symptoms of lipidema? 10:31.907 --> 10:35.809 [SPEAKER_02]: So we already talked about one lower limb enlargement. 10:35.829 --> 10:37.969 [SPEAKER_02]: Again, predominantly affects the lower limbs. 10:38.030 --> 10:41.671 [SPEAKER_02]: There's a disproportionate increase in adipose tissue around the legs. 10:42.211 --> 10:54.177 [SPEAKER_02]: It's typically starts during phases of weight gain that are connected to concomitant hormonal changes, such as dirt puberty, pregnancy, menopause, these large systemic hormonal changes, 10:55.017 --> 11:01.042 [SPEAKER_02]: that also typically result in weight changes, that tends to be like the where this thing starts. 11:01.522 --> 11:06.205 [SPEAKER_02]: Again, the weight gain is symmetrical in both legs, although it disproportionate from the rest of the body. 11:06.365 --> 11:18.574 [SPEAKER_02]: So, classically, the women have a relatively lean or normal sort of wacer conference, perhaps even hip circumference as well, but they store a lot of fat in their legs. 11:18.874 --> 11:19.655 [SPEAKER_02]: It's on both sides. 11:19.975 --> 11:26.220 [SPEAKER_02]: It spares the feet when it's in the lower extremities and rarely when it presents with the upper extremities, it also spares the hands. 11:26.620 --> 11:32.525 [SPEAKER_02]: There also may be some firm subcutaneous nodules of fat subcutaneous referring to under the skin. 11:32.885 --> 11:35.828 [SPEAKER_02]: So if you want to use that term later to impress people, you have my permission. 11:36.608 --> 11:37.749 [SPEAKER_02]: So that's one of these symptoms. 11:38.069 --> 11:39.230 [SPEAKER_02]: Another symptom is pain. 11:39.370 --> 11:44.593 [SPEAKER_02]: Again, this is important because painless sort of lower limb enlargement is probably not lipidema. 11:45.093 --> 11:51.717 [SPEAKER_02]: The pain occurs typically later after the fat accumulation has occurred and is typically associated with further weight gain. 11:52.518 --> 11:59.602 [SPEAKER_02]: So some people describe this as a feeling of like heavy legs, but it also can just present like more typically as pain. 12:00.282 --> 12:08.684 [SPEAKER_02]: And again, with the pain and the symmetrical lower limb enlargement that spares the feet, you're pretty much dealing with lipidema, but you got to rule out other causes. 12:08.704 --> 12:09.784 [SPEAKER_02]: We'll talk about that here shortly. 12:10.304 --> 12:14.225 [SPEAKER_02]: These patients also tend to exhibit easy bruise ability. 12:15.345 --> 12:24.767 [SPEAKER_02]: And we think that's a in relationship to maybe a poor structure in adequate sort of architecture in the capillaries, those are the little blood vessels. 12:25.207 --> 12:28.768 [SPEAKER_02]: For example, so you can get some destruction of those blood leaks out, you get some bruising. 12:29.588 --> 12:34.153 [SPEAKER_02]: Symptoms tend to get worse throughout the day, so you can see the overlap here through other causes of edema. 12:35.354 --> 12:41.740 [SPEAKER_02]: Interestingly, lipidema traditionally does not progress in weight-stable individuals. 12:42.901 --> 12:46.024 [SPEAKER_02]: I'll say that again, typically lipidema does not progress, meaning that it gets worse. 12:46.085 --> 12:51.150 [SPEAKER_02]: The pain gets worse, the enlargement of the lower extremities gets worse in folks who do not gain weight. 12:51.670 --> 12:56.294 [SPEAKER_02]: That being said, people traditionally do gain weight throughout the lifespan up into a certain point. 12:56.394 --> 12:59.397 [SPEAKER_02]: So that typically doesn't apply to most patients. 13:00.798 --> 13:10.947 [SPEAKER_02]: And yeah, obesity as we'll talk about is a very significant, not only risk factor for developing life and even but also as it gets worse that can cause some progression of the condition. 13:11.807 --> 13:17.210 [SPEAKER_02]: Other symptoms that are associated with lipidema, I have to do with mental health concerns. 13:17.831 --> 13:27.136 [SPEAKER_02]: It's been shown that about eighty percent of women with lipidema have some mental health sort of condition, depression, major depression disorder being most common. 13:27.596 --> 13:29.558 [SPEAKER_02]: Now, it was thought originally that 13:30.458 --> 13:32.079 [SPEAKER_02]: Maybe these folks got the lipidema. 13:32.739 --> 13:36.140 [SPEAKER_02]: It happened first and then they subsequently developed this mental health condition. 13:36.620 --> 13:47.765 [SPEAKER_02]: But some pretty, as we would say, elegant study design has shown that the majority of these mental health comorbidities happen before people develop lipidema. 13:48.205 --> 13:53.327 [SPEAKER_02]: So it could be causal, you know, potentially contributing to the, to the development of lipidema. 13:54.127 --> 14:01.215 [SPEAKER_02]: But yeah, there's going to be some folks who were previously had no mental health issue and then develop it after the development of Lypadema. 14:01.235 --> 14:02.317 [SPEAKER_02]: OK. 14:03.490 --> 14:05.352 [SPEAKER_02]: Who gets lipidema? 14:05.492 --> 14:10.556 [SPEAKER_02]: As we mentioned, it's mostly in women, overwhelming majority has to do women. 14:10.636 --> 14:19.043 [SPEAKER_02]: We think there's some role of estrogen here, but it had, there have been case reports in men, particularly those with liver disease and or testosterone deficiency. 14:19.063 --> 14:21.525 [SPEAKER_02]: These are both high estrogen, relatively speaking states. 14:22.305 --> 14:23.706 [SPEAKER_02]: The true incidence is unknown. 14:24.027 --> 14:26.629 [SPEAKER_02]: So I can't tell you, this many people, a lot of a hundred thousand get it. 14:26.649 --> 14:29.071 [SPEAKER_02]: It's been estimated to be one out of every seventy two thousand. 14:29.892 --> 14:35.177 [SPEAKER_02]: adults, but the incidence is truly unknown, mostly due to confusion with lymphedema. 14:35.498 --> 14:49.033 [SPEAKER_00]: Yeah, I don't buy any prevalence estimate based on, you know, I bet you could survey tons of my colleagues, for example, and though something like I've never heard of that, which is unfortunate, but also shows that there's likely to be very little validity to prevalence estimates. 14:49.393 --> 14:51.834 [SPEAKER_02]: Yeah, so all these numbers are likely under estimates. 14:52.194 --> 14:55.215 [SPEAKER_02]: It under reported under diagnosed confused in diagnoses. 14:56.635 --> 15:05.638 [SPEAKER_02]: But yet, estimated to be six and a half percent of women in the adult women in the United States and fifteen to eighteen percent of adult women in the European Union. 15:06.138 --> 15:08.459 [SPEAKER_02]: But again, it's probably higher than how much higher. 15:08.479 --> 15:11.519 [SPEAKER_02]: I don't care to speculate, but it's higher. 15:12.240 --> 15:13.300 [SPEAKER_02]: I would feel confident in saying that. 15:14.350 --> 15:16.713 [SPEAKER_02]: Risk factors for developing lipidema. 15:17.093 --> 15:19.015 [SPEAKER_02]: Big one is going to be obesity here. 15:20.076 --> 15:24.882 [SPEAKER_02]: Greater than ninety percent of those with lipidema are individuals with obesity or overweight. 15:25.640 --> 15:46.511 [SPEAKER_02]: Now, like edema itself does not cause overweight or obesity, if that would require like edema to be present before the person developed obesity, rather increasing body mass, increases the risk of developing like edema, usually through a progression from what we would call lipohypertory, so just an expansion of those fat cells in, in this case, the lower extremities. 15:48.272 --> 15:52.195 [SPEAKER_02]: Also, we think that hormonal abnormalities play a role here. 15:52.455 --> 15:59.681 [SPEAKER_02]: So for example, high estrogen states in men, like we talked about liver failure, testosterone deficiency, also potentially high estrogen states in women. 15:59.921 --> 16:03.705 [SPEAKER_02]: Because again, the onset of this condition happens during these sort of distinct 16:04.365 --> 16:11.213 [SPEAKER_02]: phases in life, puberty, pregnancy, menopause, although menopause wouldn't really be a high estrogen state, but some hormonal change there. 16:11.573 --> 16:20.022 [SPEAKER_02]: And in fact, women with polycystic ovarian syndrome have a higher prevalence of lipidema, and that's a high testosterone state. 16:20.083 --> 16:24.527 [SPEAKER_02]: So some hormonal abnormality seems to be contributory here. 16:25.108 --> 16:30.009 [SPEAKER_02]: But the big smoking gun here as far as causation tends to be genetics. 16:31.390 --> 16:35.131 [SPEAKER_02]: The majority of lipidema appears to be autosomal dominant. 16:35.151 --> 16:42.593 [SPEAKER_02]: So you have, you know, forty six pair of forty six chromosomes, twenty three from your dad, twenty two of them are autosomal. 16:42.913 --> 16:45.274 [SPEAKER_02]: and one of them are sex chromosomes. 16:45.974 --> 16:52.577 [SPEAKER_02]: So we think that the majority of lipidema is genetically derived from an autosominal, autosomal dominant inheritance. 16:52.817 --> 16:54.578 [SPEAKER_02]: So it's common that people say, oh, my mom had this. 16:54.838 --> 16:56.219 [SPEAKER_02]: That's the common report here. 16:56.499 --> 17:04.643 [SPEAKER_02]: Although other genes can be involved, so Williams syndrome, for example, is another genetic condition that usually picked up in infancy in more childhood. 17:05.023 --> 17:09.705 [SPEAKER_02]: And those kids tend to have be at higher risk of developing lipidema later on. 17:10.245 --> 17:20.452 [SPEAKER_02]: So to summarize all of this, given the right genetic predisposition for like Padema, weight gain tends to trigger the exacerbation or the recognition of this condition. 17:20.772 --> 17:21.513 [SPEAKER_02]: That's on the right to you. 17:22.013 --> 17:37.063 [SPEAKER_00]: Yeah, I know we're going to get into some of the little more pathophysiologic detail, the interesting stuff here in a moment, but it does kind of require that baseline susceptibility and then as the fat tissue compartment kind of expands a bit, it might be more susceptible to being 17:37.723 --> 17:51.448 [SPEAKER_00]: lay down in a pathological way, or perpetuating kind of pathological cycles leading to what we'll talk about in a bit, inflammation, fibrosis, things like that, to where the fat tissue itself is pathologic and functioning differently. 17:51.488 --> 18:01.332 [SPEAKER_00]: And it's like identifiably different, even under a microscope compared with a few sampled traditional body fat or arguably even probably body fat from a different area of the same person's body. 18:02.086 --> 18:03.727 [SPEAKER_00]: that is not in this particular compartment. 18:04.087 --> 18:04.327 [SPEAKER_02]: Yeah. 18:04.647 --> 18:04.947 [SPEAKER_02]: Yeah. 18:05.027 --> 18:06.768 [SPEAKER_02]: So actually, that's a perfect segue. 18:06.828 --> 18:07.668 [SPEAKER_02]: Like, all right. 18:07.888 --> 18:10.369 [SPEAKER_02]: Well, how does like the demon develop and cause symptoms in the first place? 18:10.889 --> 18:12.290 [SPEAKER_02]: The true pathogenesis. 18:12.310 --> 18:21.473 [SPEAKER_02]: So like all of the steps and all of the molecules and hormones and signaling factors and genetic sort of, you know, it this does this other thing and causes this final thing to happen. 18:21.853 --> 18:22.393 [SPEAKER_02]: We don't really know. 18:22.794 --> 18:26.175 [SPEAKER_02]: It's still unclear, but the current prevailing theory 18:26.735 --> 18:45.802 [SPEAKER_02]: is that this genetic predisposition likely produces an abnormal pattern in distribution of estrogen receptors in the fat tissue, which leads to abnormal fat cell differentiation and function and also potential abnormality in like elastic tissue formation and stuff like blood vessels connective tissue and so on. 18:46.202 --> 18:47.983 [SPEAKER_02]: So through this theory, 18:48.683 --> 19:03.096 [SPEAKER_02]: There is a hyperplasia, so increase in number, and hypertrophy, increase in size of fat cells in the legs, secondary to this genetic abnormality, and also the capillaries, the blood vessels in the area, are kind of weird, they're fragile. 19:03.556 --> 19:14.505 [SPEAKER_02]: And so what you get is this weird functioning fat cells, too many of them, potentially, and they're too big, and by the way, the blood supply to that tissue is kind of messed up too, and so you get some damage. 19:15.406 --> 19:26.972 [SPEAKER_02]: lack of blood supply, lack of oxygen to the area that call that hypoxia, inflammation results and you get necrosis and fibrosis of the fat tissue and that can lead to pain. 19:27.613 --> 19:37.218 [SPEAKER_02]: 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. 19:38.719 --> 19:47.564 [SPEAKER_02]: Yeah, it's funny that individuals with like a demo, when you kind of look at their inflammatory profile, I know that's kind of like a meaningless phrase, like the heck you're talking about. 19:47.584 --> 19:53.007 [SPEAKER_02]: Like just the levels of inflammation, or if you took a biopsy of their tissue, can you see evidence of inflammation? 19:53.387 --> 19:54.108 [SPEAKER_02]: Well, you sure do. 19:55.028 --> 19:57.329 [SPEAKER_02]: Pretty much, like you could sample the area of the legs. 19:57.349 --> 20:02.172 [SPEAKER_02]: You're gonna see more inflammatory infiltrate immune system function, all that stuff going on. 20:02.672 --> 20:04.954 [SPEAKER_02]: You take a blood sample, you're gonna see higher rates of inflammation. 20:06.095 --> 20:14.464 [SPEAKER_02]: And so the pain that people are experiencing, it's not just related to like, you got this inflammation, you got this tissue damage, but it's certainly a contributing. 20:14.704 --> 20:20.510 [SPEAKER_02]: It's a biological sort of driver of that pain experience, which can obviously vary amongst individuals. 20:20.851 --> 20:21.692 [SPEAKER_02]: And you add to that. 20:22.372 --> 20:38.304 [SPEAKER_02]: some mental health sort of stuff going on and decreased sort of activity levels due to some limited mobility due to the likes being larger and yeah the pain sensitivity being greater is kind of an unexpected response there. 20:38.834 --> 20:53.661 [SPEAKER_00]: Yeah, we know that inflammation in general either local inflammation or systemic inflammation has an effect to basically sensitize the nosy sectors or the nerve endings that facilitate or part of the biological pathway for the experience of pain. 20:53.681 --> 21:02.725 [SPEAKER_00]: 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. 21:03.185 --> 21:05.106 [SPEAKER_00]: Let's try to think about whether there's some sort of a 21:06.232 --> 21:09.473 [SPEAKER_00]: analogous condition of another tissue type here in the body. 21:09.553 --> 21:24.675 [SPEAKER_00]: And it's not a perfect one, but I'm trying to convey the concept of like 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. 21:25.155 --> 21:29.996 [SPEAKER_00]: And one, again, not a perfect one, but came to mind is like people with the milestone. 21:30.356 --> 21:31.657 [SPEAKER_00]: I literally think of that. 21:31.757 --> 21:33.317 [SPEAKER_00]: Yeah, we're both, we're both think of this. 21:34.097 --> 21:52.533 [SPEAKER_00]: of you have, you know, 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 of the distinct aspect, but it is dysfunctional. 21:52.713 --> 21:56.717 [SPEAKER_00]: It is not, it does not function as healthy, quote unquote, normal muscle does. 21:57.437 --> 22:03.844 [SPEAKER_00]: And even, you know, among those without this condition, there is a role for, quote, unquote, healthy, normal amounts of, of body fat. 22:03.884 --> 22:05.506 [SPEAKER_00]: There's an important role that that plays. 22:06.567 --> 22:13.434 [SPEAKER_00]: We know that from, from other conditions, for example, like extreme starvation experiments and people with lipodistrophy who cannot lay down enough body fat. 22:13.474 --> 22:18.119 [SPEAKER_00]: They have tons of problems and incidentally enough developed diabetes immediately because they have no storage. 22:19.040 --> 22:20.482 [SPEAKER_00]: site for excess energy. 22:20.922 --> 22:34.599 [SPEAKER_00]: And so there is an important role for 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. 22:34.659 --> 22:37.943 [SPEAKER_00]: Here you get dysfunctional body fat that doesn't work properly and incidentally 22:38.383 --> 22:44.847 [SPEAKER_00]: in the setting of the information affecting nervous system function and the impact on pain experience leads to that as an additional component. 22:44.887 --> 22:58.735 [SPEAKER_00]: 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. 22:59.075 --> 23:20.320 [SPEAKER_02]: 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 at all folks, but not everyone, yeah, but the majority of the time. 23:21.120 --> 23:22.620 [SPEAKER_02]: All right, let's move on to diagnosis. 23:22.640 --> 23:26.021 [SPEAKER_02]: So how is lipidema diagnosed? 23:26.101 --> 23:29.662 [SPEAKER_02]: Well, this is a clinical diagnosis, which basically means that your doctor just makes it up. 23:30.222 --> 23:39.085 [SPEAKER_00]: Yeah, the very common phrase to call something a clinical diagnosis, which for a long time I've held is a kind of a silly phrase and there's actually a well known 23:39.585 --> 23:45.512 [SPEAKER_00]: paper in among internal medicine nerds, something to the effect of like a clinical diagnosis like, isn't that all of them? 23:45.632 --> 23:47.154 [SPEAKER_00]: Basically, they talk to your doctor. 23:47.494 --> 23:51.438 [SPEAKER_00]: But the point is that there's not like a single simple lab test that you can check that'll cleanse the diagnosis. 23:51.458 --> 23:55.123 [SPEAKER_00]: You have to pull together different clues and different pieces of information to get there. 23:55.610 --> 23:58.373 [SPEAKER_02]: Yeah, and importantly, it's really a diagnosis of exclusion. 23:58.713 --> 24:04.919 [SPEAKER_02]: So for example, you need to roll that rule out other sort of like organ dysfunction that could cause edema. 24:05.219 --> 24:06.560 [SPEAKER_02]: We talked about a few of those at the beginning. 24:06.600 --> 24:07.381 [SPEAKER_02]: So Cardiogenic. 24:07.561 --> 24:09.603 [SPEAKER_02]: So stuff from the heart, stuff from the liver, stuff from the kidney. 24:09.623 --> 24:11.285 [SPEAKER_02]: You need to rule out lymphedema. 24:11.885 --> 24:21.111 [SPEAKER_02]: which would be another reason why the lower extremities would be swollen, although, again, you wouldn't expect pain, but, you know, not everybody's diagnosis reads the textbook, and so things can be different. 24:21.231 --> 24:23.012 [SPEAKER_02]: But yeah, it's a clinical diagnosis of exclusion. 24:23.032 --> 24:29.256 [SPEAKER_02]: There's not like a blood test, a genetic test, an image that you can take that's going to like definitively, it is this. 24:29.316 --> 24:39.503 [SPEAKER_02]: You 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, you know, clinical presentation, but it's not like a demon. 24:40.043 --> 24:51.937 [SPEAKER_02]: But again, the two criteria that we're really focusing here are on the disproportionate symmetrical increase in adipose tissue, fat tissue on both legs, spares the feet. 24:52.798 --> 24:55.841 [SPEAKER_02]: And it's associated with pain in these affected areas. 24:57.362 --> 25:05.765 [SPEAKER_02]: There's another thought based on the latest guidelines to recommend also using this international classification of functioning disability and health survey. 25:05.785 --> 25:07.466 [SPEAKER_02]: It's called abbreviated ICF. 25:07.866 --> 25:17.849 [SPEAKER_02]: This is a survey-based tool that is kind of assesses somebody's quality life, their health profile, so it can be useful to kind of track and monitor things over time. 25:19.170 --> 25:22.953 [SPEAKER_02]: You can use some additional imaging, right? 25:23.153 --> 25:25.115 [SPEAKER_02]: So lymphose can tigraphy. 25:25.395 --> 25:30.219 [SPEAKER_02]: This can be used for patients with a elevated BMI greater than thirty. 25:30.679 --> 25:32.661 [SPEAKER_02]: Basically, it looks at your lymphatic system's function. 25:33.081 --> 25:35.143 [SPEAKER_02]: So just to make sure it's not lymphedema, for example. 25:36.144 --> 25:39.649 [SPEAKER_02]: You can also have lipo lymphedema where you have both lipoed. 25:40.450 --> 25:42.073 [SPEAKER_02]: Lipedema and lymphedema together. 25:42.093 --> 25:42.914 [SPEAKER_02]: That happens. 25:44.216 --> 25:50.164 [SPEAKER_02]: And so, yeah, there's not really a role in that for diagnosis, but again, to rule out, oh, this is lymphedema. 25:50.917 --> 25:53.578 [SPEAKER_00]: Yeah, that's not very commonly performed imaging test. 25:53.598 --> 26:02.440 [SPEAKER_00]: 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? 26:02.641 --> 26:05.261 [SPEAKER_00]: It was not as part of a diagnostic evaluation for a lipidema. 26:05.641 --> 26:05.801 [SPEAKER_02]: Yeah. 26:06.082 --> 26:06.522 [SPEAKER_02]: Yeah. 26:06.682 --> 26:13.804 [SPEAKER_02]: MRIs have also been performed usually preoperatively, but for some planning, but again, just to make sure there's not anything else going on. 26:14.484 --> 26:20.406 [SPEAKER_02]: Not a surgeon, but I would imagine you wouldn't want to cut into an area without some pictures of what you're doing. 26:21.056 --> 26:23.097 [SPEAKER_00]: Yeah, most often useful for surgical planning. 26:23.177 --> 26:30.519 [SPEAKER_00]: 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. 26:30.819 --> 26:31.559 [SPEAKER_00]: Yeah, there you go. 26:32.279 --> 26:32.619 [SPEAKER_02]: All right. 26:32.840 --> 26:38.541 [SPEAKER_02]: So we've talked about what is lipidema, what causes it, who gets it and how it's diagnosed. 26:38.561 --> 26:40.762 [SPEAKER_02]: Let's talk now about how to treat 26:41.302 --> 26:57.862 [SPEAKER_02]: Like a demon, we're going to use a multi-pronged interdisciplinary as 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. 26:58.143 --> 26:58.523 [SPEAKER_02]: They are. 26:59.324 --> 27:04.986 [SPEAKER_02]: I mean, look, if barbell medicines, the number one like promoter of exercise in the medical space, these people may be number two. 27:06.007 --> 27:09.188 [SPEAKER_02]: Like if I met them, I would definitely buy them a beer. 27:10.068 --> 27:11.949 [SPEAKER_02]: Yeah, I'm very impressed. 27:12.589 --> 27:17.071 [SPEAKER_02]: And the main role here of exercise is not really from like a weight management standpoint. 27:17.471 --> 27:32.107 [SPEAKER_02]: And they make big go through extensive detail and in 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 because one of the big issues here 27:32.908 --> 27:40.534 [SPEAKER_02]: with lipidema is that due to the pain and due to the enlargement of the limbs, these folk their mobility tends to suffer. 27:40.935 --> 27:50.663 [SPEAKER_02]: 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. 27:51.343 --> 27:55.486 [SPEAKER_02]: So their big push years get people active, get people exercising. 27:56.266 --> 28:06.093 [SPEAKER_02]: 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 lipidine that it tends to decrease the inflammation. 28:06.933 --> 28:16.477 [SPEAKER_02]: in the excess adipose tissue, intends to improve their function because they're doing so, you know, they're basically practicing and exercise. 28:16.777 --> 28:21.019 [SPEAKER_02]: And there's going to be some exercise induced sort of analgesias, so I'm sort of pain reduction. 28:21.119 --> 28:23.560 [SPEAKER_02]: So, you know, what's the recommendation here? 28:24.080 --> 28:26.801 [SPEAKER_02]: It's the same as the current physical activity guideline. 28:26.841 --> 28:27.502 [SPEAKER_02]: They should live weights. 28:28.222 --> 28:29.103 [SPEAKER_02]: They should do conditioning. 28:29.844 --> 28:38.813 [SPEAKER_02]: I kind of view any specific considerations around exercise to be very similar to other conditions that are associated with limited mobility. 28:38.893 --> 28:46.640 [SPEAKER_02]: So for example, like COPD, right, I'm obviously these are two distinctly different diagnoses and different sort of symptoms. 28:47.381 --> 28:51.824 [SPEAKER_02]: But individuals with COPD have limited capacity to participate in traditional conditioning. 28:52.364 --> 28:53.545 [SPEAKER_02]: They start breathing too hard or whatever. 28:54.166 --> 28:56.387 [SPEAKER_02]: And so you're like, well, they still need to exercise. 28:56.407 --> 28:57.648 [SPEAKER_02]: So what do intervals? 28:58.689 --> 29:00.050 [SPEAKER_02]: That's been tested in COPD folks. 29:00.090 --> 29:05.673 [SPEAKER_02]: They tend to tolerate them better and get good benefits from that resistance training seems to be preferred by these individuals. 29:05.733 --> 29:08.996 [SPEAKER_02]: And so I kind of favor something like that. 29:09.656 --> 29:16.383 [SPEAKER_02]: 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. 29:16.463 --> 29:19.666 [SPEAKER_02]: I'm able to participate in this, but these other things are more challenge. 29:19.686 --> 29:23.410 [SPEAKER_02]: I feel like I can't actually work out and all by the way, they make me feel not so great. 29:23.951 --> 29:25.512 [SPEAKER_02]: And so I think it's just going to be individualized. 29:26.245 --> 29:32.294 [SPEAKER_02]: which kind of takes us back to our general sentiment regarding like what sort of considerations don't need to make around this particular medical condition. 29:32.334 --> 29:35.359 [SPEAKER_02]: It's like, well, they're none specific to the medical condition. 29:35.399 --> 29:38.824 [SPEAKER_02]: It's more specific to the individual, which you were going to do anyway, right? 29:39.825 --> 29:40.126 [SPEAKER_02]: Right. 29:40.727 --> 29:40.907 [SPEAKER_00]: Yes. 29:41.588 --> 29:57.676 [SPEAKER_00]: Yeah, this is such a common thing that I wish we could, I don't know, how we get more people to grasp the concept is that the diagnostic label in most situations is not the predominant driver of specific exercise-related modifications. 29:57.716 --> 30:10.663 [SPEAKER_00]: 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, 30:11.423 --> 30:15.044 [SPEAKER_00]: You will be able to get a long way, even if you didn't know about their medical condition. 30:15.505 --> 30:18.066 [SPEAKER_00]: Again, not in every case, there are certainly some situations. 30:18.186 --> 30:29.090 [SPEAKER_00]: 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 going to like certainly guide my decision making pretty hard. 30:29.710 --> 30:34.752 [SPEAKER_00]: But those are certainly a minority of situations, whereas just getting a sense of like, hey, where's the person at? 30:34.812 --> 30:35.392 [SPEAKER_00]: What can they tolerate? 30:35.412 --> 30:36.173 [SPEAKER_00]: And where are we trying to get? 30:36.999 --> 30:44.392 [SPEAKER_00]: 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. 30:44.713 --> 30:45.594 [SPEAKER_00]: Yeah, exactly. 30:46.095 --> 30:48.560 [SPEAKER_02]: So TLDR exercise promotion. 30:48.580 --> 30:48.640 [SPEAKER_02]: Wow. 30:50.283 --> 30:53.584 [SPEAKER_00]: Shocking development on the program is in my case. 30:54.845 --> 31:09.851 [SPEAKER_02]: Equally, a shocking is a recommendation by the current guidelines and our corroboration that individuals with lipid image should be recommended and counseled and supported to adopt a health promoting dietary pattern. 31:09.911 --> 31:16.153 [SPEAKER_02]: Now, some of this is related to weight management, which we'll discuss in a little more detail in about the hundred and twenty seconds. 31:16.873 --> 31:21.797 [SPEAKER_02]: But there are also additional non-weight-related health benefits of just changing the dietary pattern. 31:21.857 --> 31:27.261 [SPEAKER_02]: That's a lot of other chronic medical conditions that individuals are likely to have. 31:27.301 --> 31:31.244 [SPEAKER_02]: So high blood pressure, for example, would be one insulin resistance. 31:31.665 --> 31:36.808 [SPEAKER_02]: For example, shore weight loss does tend to help in addition to the just adoption of a health-promoting dietary pattern. 31:37.109 --> 31:40.411 [SPEAKER_02]: But the diet itself also tends to improve those sort of things. 31:40.471 --> 31:43.434 [SPEAKER_02]: And so if you can get individuals to move towards a 31:44.214 --> 31:54.560 [SPEAKER_02]: more minimally processed, or unprocessed, dietary pattern that has the correct amount of energy for their support, not only physical activity, but also a healthy body composition and body weight. 31:55.561 --> 32:03.245 [SPEAKER_02]: And they can adhere to that likely requiring some modification of their food environment, their cooking skills, the foods they shop for, etc. 32:03.485 --> 32:03.886 [SPEAKER_02]: All of that. 32:05.113 --> 32:07.395 [SPEAKER_02]: Evergreen will be recommended for everyone. 32:07.635 --> 32:09.256 [SPEAKER_02]: So no surprise that it's recommended here. 32:09.756 --> 32:27.788 [SPEAKER_02]: But I did want to point out that these guidelines, which you can't all this stuff is linked in the show notes below, they take against special care to recommend against any sort of like short term diet, short term rapid weight loss kind of diet because they're one of their contentions that I think is it feels again truthy. 32:29.075 --> 32:40.818 [SPEAKER_02]: is that the association of lipidema with obesity has really kind of hamstrung the discussion of not only that pathophysiology behind lipidema, but also its management. 32:40.838 --> 32:42.659 [SPEAKER_02]: Because the recommendation is that, oh, it just loses weight. 32:43.239 --> 32:43.679 [SPEAKER_02]: Just do that. 32:43.899 --> 32:49.981 [SPEAKER_02]: And unfortunately, lifestyle alone, that's diet exercise, sleep, et cetera. 32:50.261 --> 32:54.362 [SPEAKER_02]: Now that it has no effect on weight management, to set the effect tends to be 32:55.528 --> 32:58.249 [SPEAKER_02]: relatively modest in most folks. 32:58.810 --> 33:08.294 [SPEAKER_02]: And the majority of folks are not going to be able to lose a sufficient amount of weight to adequately get them to a, you know, a healthy body composition, healthy body weight. 33:08.534 --> 33:19.300 [SPEAKER_02]: And so their thought is like, look, the recommendation follow this diet, whatever, people just yo yo and then an obtaining more weight than where they were in the first place, which would worsen like edema in these folks. 33:19.600 --> 33:19.720 [SPEAKER_00]: Yeah. 33:20.352 --> 33:21.892 [SPEAKER_00]: Yeah, I'm little to add, I agree. 33:22.152 --> 33:24.633 [SPEAKER_00]: And I think this requires careful discussion and recognition. 33:24.833 --> 33:24.953 [SPEAKER_00]: Yeah. 33:24.973 --> 33:27.294 [SPEAKER_02]: Well, as long as we're talking about weight management, let's keep it going. 33:28.594 --> 33:42.538 [SPEAKER_02]: Weight stability is important here, because gaining weight would increase not only the risk of somebody who's got this sort of painless, lipo hypertrophy developing into lipidema, but also weight gain in an individual lipidema makes the symptoms worse, generally speaking. 33:43.098 --> 33:56.881 [SPEAKER_02]: And while some have argued that the fat in the legs in folks with lipidema is not the same as stored fat in obesity, which suggests that it could not be lost through diet, exercise, or other methods of weight loss, this is not that's not an evidence-based take. 33:57.781 --> 34:07.324 [SPEAKER_02]: I mean, I've seen even this just this week, and I don't know if it's my phone's listening to me or whatever, but on my explore page, it's, you know, people just talking about lipidema and say, yeah, it doesn't respond to exercise and diet. 34:07.704 --> 34:08.304 [SPEAKER_02]: I'm like, well, 34:09.807 --> 34:12.669 [SPEAKER_02]: That's kind of true if you say that exercise and diet doesn't really cause weight loss. 34:13.569 --> 34:18.973 [SPEAKER_02]: Although I would say that exercise tends to reduce the symptoms based on existing evidence so that kind of an issue there. 34:19.493 --> 34:25.177 [SPEAKER_02]: 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. 34:25.357 --> 34:26.958 [SPEAKER_02]: And so surgery is the only option. 34:27.018 --> 34:28.338 [SPEAKER_02]: That's definitively not the case. 34:28.379 --> 34:34.923 [SPEAKER_02]: You look at reams and reams of evidence, weight loss tends to promote loss of fat mass in the lower extremities. 34:34.943 --> 34:38.465 [SPEAKER_02]: And the best data we have on this is from metabolic bariatric surgery. 34:39.330 --> 34:47.156 [SPEAKER_02]: mainly because the folks lose so much weight that if there was this sort of disproportionate retention in fat. 34:47.476 --> 34:51.479 [SPEAKER_02]: So imagine a person, they went underwent metabolic bariatric surgery and they lost a hundred pounds. 34:51.759 --> 34:51.919 [SPEAKER_00]: Yeah. 34:52.040 --> 34:53.741 [SPEAKER_02]: They lost nothing from their legs, though. 34:53.761 --> 34:54.201 [SPEAKER_02]: Right. 34:54.241 --> 34:54.782 [SPEAKER_02]: Like dang. 34:55.780 --> 35:01.164 [SPEAKER_02]: This, it is unresponsive to any sort of traditional type of late management, but that is not the case. 35:01.204 --> 35:04.446 [SPEAKER_02]: You see a proportional loss in body fat and lower extremities. 35:04.866 --> 35:10.550 [SPEAKER_00]: Yeah, it reminds me again to draw some analogies from other areas, also like the concept of it doesn't risk quote unquote respond. 35:11.070 --> 35:12.471 [SPEAKER_00]: What exactly are we referring to? 35:12.491 --> 35:14.272 [SPEAKER_00]: And how are we measuring response, right? 35:14.292 --> 35:15.593 [SPEAKER_00]: So there's like the pain element. 35:15.933 --> 35:19.656 [SPEAKER_00]: There's the actual amount size potentially how that impacts the 35:20.016 --> 35:22.857 [SPEAKER_00]: kind of cosmetic appearance of the legs. 35:23.297 --> 35:25.518 [SPEAKER_00]: There's the inflammatory aspect, things like that. 35:25.598 --> 35:29.559 [SPEAKER_00]: And so an analogy that I'm thinking of here is in the context of fatty liver disease. 35:30.720 --> 35:40.383 [SPEAKER_00]: 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. 35:40.823 --> 35:46.827 [SPEAKER_00]: A lot of that is similar to what's described in the fat mass in lipidema, where there's this inflammation in fibrosis that's happening. 35:47.407 --> 35:55.412 [SPEAKER_00]: And in fatty liver disease, we know that there are certain thresholds of body weight loss thresholds, for example, to lead to certain outcomes. 35:55.832 --> 36:01.316 [SPEAKER_00]: So if we want to improve the inflammation, if we want to improve the fibrosis, if we want to 36:01.676 --> 36:06.157 [SPEAKER_00]: you know, mitigate the risk we can't reverse cirrhosis, but mitigate the risk of cirrhosis most significantly. 36:06.197 --> 36:13.780 [SPEAKER_00]: There are certain thresholds of do you need five percent body weight loss for this seven and a half percent for this ten or fifteen percent weight loss to achieve this particular outcome. 36:14.200 --> 36:27.264 [SPEAKER_00]: And so here similarly it might be a kind of a similar almost threshold based model where through traditional quote unquote die in 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. 36:27.864 --> 36:30.665 [SPEAKER_00]: And so you, does that, does that mean that 36:31.545 --> 36:34.192 [SPEAKER_00]: in comment, what we'll call common obesity regular body fat. 36:34.432 --> 36:36.156 [SPEAKER_00]: Does it respond to diet and exercise? 36:36.617 --> 36:38.201 [SPEAKER_00]: Or is it more threshold type effect? 36:38.582 --> 36:40.025 [SPEAKER_00]: Well, when we induce 36:41.033 --> 36:51.217 [SPEAKER_00]: greater degrees of weight loss, for example, using antibody loss from somebody on some of our modern GLP ones. 36:51.237 --> 36:56.519 [SPEAKER_00]: We see a much more potent response in terms of fat loss and improvements and inflammation and various other issues. 36:56.859 --> 37:02.902 [SPEAKER_00]: And then as you're pointing out, when we have metabolic bariatric surgery, you know, twenty two, twenty five, thirty percent body weight loss. 37:02.942 --> 37:04.442 [SPEAKER_00]: We similarly see that as well. 37:04.502 --> 37:06.023 [SPEAKER_00]: So I'm curious how much of it. 37:06.423 --> 37:20.917 [SPEAKER_00]: You know, is thought even though this fat tissue is distinct and unique from, you know, 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. 37:21.327 --> 37:25.008 [SPEAKER_00]: be the case in most situations, if a certain sufficient threshold is reached. 37:25.808 --> 37:26.348 [SPEAKER_02]: Yep, agreed. 37:27.309 --> 37:39.492 [SPEAKER_02]: There may be a role upcoming for, you know, pharmacotherapy, related options, obviously people are familiar with some aglutide, so we'll go via those antipic, but there's epitides of zepound, for example. 37:40.512 --> 37:44.693 [SPEAKER_02]: might actually have a little bit greater role to play. 37:44.973 --> 37:48.634 [SPEAKER_02]: There's not data here, you know, not randomized controlled trials on this. 37:48.874 --> 37:52.354 [SPEAKER_02]: But the mechanisms are certainly interesting, so let's talk about those for a second. 37:52.694 --> 37:59.196 [SPEAKER_02]: Yes, sure, turns epitide seems to be a little bit more potent with respect to the effect on weight loss. 37:59.896 --> 38:07.197 [SPEAKER_02]: Secondary to like appetite, satiety, feelings of fullness, modulation, compared to like some agglutide, that seems to be, you know, 38:07.637 --> 38:18.626 [SPEAKER_02]: Pretty much true, but there's also been this sort of knock-on effect from Tersepatide that it as reduces the inflammation in adipose tissue in fat tissue and its dysfunction. 38:18.706 --> 38:22.509 [SPEAKER_02]: We've seen that in, you know, heart failure with preserved ejection fraction. 38:22.529 --> 38:26.472 [SPEAKER_02]: We've seen that in, you know, non-alcoholic fatty liver disease. 38:26.512 --> 38:30.995 [SPEAKER_02]: Now known as metabolic associated stytosis, also PCOS. 38:31.856 --> 38:34.198 [SPEAKER_02]: So that might be useful in a condition where somebody has 38:34.878 --> 38:37.460 [SPEAKER_02]: at a post tissue inflammation and dysfunction, like lipidema. 38:39.201 --> 38:41.923 [SPEAKER_02]: So yeah, there's some interesting, maybe mechanisms here. 38:42.864 --> 38:55.453 [SPEAKER_02]: We'll see, I don't know, I don't feel confident saying, triseptatides going to benefit lipidema 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. 38:56.178 --> 38:57.299 [SPEAKER_00]: Yeah, super interesting. 38:57.399 --> 38:58.860 [SPEAKER_00]: I'm very interested to see. 38:58.880 --> 39:05.844 [SPEAKER_00]: 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. 39:06.385 --> 39:12.749 [SPEAKER_00]: 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 terzepotide in this situation. 39:12.829 --> 39:13.730 [SPEAKER_00]: I know that I would. 39:14.330 --> 39:20.616 [SPEAKER_00]: and seeing some pretty favorable anecdotal experiences, not that we would take that to the bank as a strong evidence for conclusion. 39:20.716 --> 39:24.820 [SPEAKER_00]: But likely, I think more likely to benefit these patients than it is to harm them. 39:25.901 --> 39:29.164 [SPEAKER_00]: While we're on the topic of medicines, there's just a couple of the thoughts that came to mind. 39:29.725 --> 39:33.529 [SPEAKER_00]: Not only some that might help here, I also be curious. 39:34.229 --> 39:38.435 [SPEAKER_00]: You know, we could look into this offline, I suppose, but medicine, like P.O. 39:38.455 --> 39:40.277 [SPEAKER_00]: Glittison, is known as a P.P.R. 39:40.297 --> 39:41.239 [SPEAKER_00]: Gamma Agnist. 39:41.299 --> 39:51.292 [SPEAKER_00]: 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 in fat tissue differentiation and things like that. 39:52.075 --> 39:53.656 [SPEAKER_00]: So I'd be curious if a medicine like P.A. 39:53.676 --> 40:00.140 [SPEAKER_00]: Glittison has any data research in the context of a lipidema, whether for benefit or for harm either way. 40:00.640 --> 40:06.463 [SPEAKER_00]: And then others would be, what medicines would be more likely to actually cause harm and like, should be avoided? 40:06.483 --> 40:11.446 [SPEAKER_00]: Because so for example, you mentioned how there's a lot of that tissue inflammation. 40:11.706 --> 40:15.809 [SPEAKER_00]: And so somebody might think, oh, well, if there's a lot of inflammation, I ought to use an anti-inflammatory. 40:15.849 --> 40:17.850 [SPEAKER_00]: So let me try some like prednisone or something like that. 40:17.870 --> 40:18.570 [SPEAKER_00]: Last zero is real. 40:18.810 --> 40:19.471 [SPEAKER_00]: Terrible idea. 40:20.271 --> 40:29.598 [SPEAKER_00]: If that's what you're using it for, now the patient needs prednisone for some other critically important reason, autoimmune inflammatory disease, something like that, sure, but not to treat this condition. 40:29.638 --> 40:31.820 [SPEAKER_00]: I would expect it to probably worsen this condition. 40:31.840 --> 40:45.149 [SPEAKER_00]: 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 to reason to believe that this might worsen lipidema so that you can more accurately 40:45.695 --> 40:47.656 [SPEAKER_00]: way those risks and benefits. 40:47.736 --> 40:49.117 [SPEAKER_00]: It's not to say you shouldn't use that drug. 40:49.157 --> 40:52.779 [SPEAKER_00]: It's just that you want to be able to accurately way those risks and benefits out. 40:52.799 --> 40:57.422 [SPEAKER_00]: What do you potentially going to gain by trying this and are you willing to possibly experience a worsening of this? 40:58.362 --> 41:02.885 [SPEAKER_00]: So yeah, GLP ones are very promising in my mind. 41:02.925 --> 41:09.088 [SPEAKER_00]: I think they're very likely to be beneficial, but we'll be interesting to see a better controlled trial data whenever that becomes available. 41:09.368 --> 41:16.896 [SPEAKER_02]: Yeah, yeah, especially in, you know, for think about it, you have to get a cohort a group of patients with lipidema that have been diagnosed correctly. 41:17.156 --> 41:17.357 [SPEAKER_00]: Yes. 41:17.417 --> 41:23.744 [SPEAKER_02]: It has not been surgerized or like whatever, you know, you'll have to it be the recruitment issues would be challenging, but not insurmountable. 41:24.084 --> 41:24.644 [SPEAKER_02]: Yeah, I agree. 41:25.245 --> 41:36.929 [SPEAKER_02]: All right, so in addition to lifestyle stuff, in addition to weight management, you know, managing the rest of the symptoms becomes in the major focus of like, you know, why would you see your doctor? 41:37.009 --> 41:37.970 [SPEAKER_02]: What's the whole point? 41:38.390 --> 41:39.891 [SPEAKER_02]: And starting, this starts with education. 41:40.531 --> 41:51.095 [SPEAKER_02]: 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 life edema that this is a chronic condition, 41:51.735 --> 41:57.598 [SPEAKER_02]: that it's mostly related to genetics, so it's not like some sort of moral failing, or anything like that. 41:58.139 --> 42:09.144 [SPEAKER_02]: I'm flot similar to just obesity generally speaking, but I think that can be helpful, especially if that is maybe the nightest or at least a factor in their sort of maybe some mental health type stuff that's going on. 42:10.085 --> 42:17.549 [SPEAKER_02]: And further, that this condition does respond to weight change and exercise, so weight loss and exercise. 42:18.029 --> 42:20.791 [SPEAKER_02]: Because if someone were of the opinion that it did not, 42:22.029 --> 42:25.333 [SPEAKER_02]: then they might be less likely to participate in those things. 42:26.053 --> 42:39.248 [SPEAKER_02]: It's kind of like with a person who has osteoarthritis, if they've been told there's wear and tear and that you can't expose the joints to too much stress, trying to get them to exercise after that if they're understanding of the condition is challenging. 42:39.568 --> 42:39.708 [SPEAKER_00]: Yeah. 42:40.129 --> 42:55.463 [SPEAKER_02]: So yeah, if you have some education that's chronic condition, genetically based response to weight loss and exercise generally speaking, can use motivational interviewing to adopt the lifestyle changes, build stuff, self efficacy through that. 42:56.203 --> 43:06.668 [SPEAKER_02]: And also it 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. 43:07.008 --> 43:21.615 [SPEAKER_02]: If somebody does have lymphedema on top of lipidema, well, that would change, but again, making sure that person knows the diagnosis, what causes it, and what things would modify their trajectory, I think, ultimately helps them make informed decisions. 43:21.915 --> 43:22.055 [SPEAKER_00]: Yeah. 43:22.295 --> 43:22.455 [SPEAKER_00]: Yeah. 43:22.816 --> 43:35.423 [SPEAKER_02]: Well said, with respect to pain because this is like one of the major symptoms used for diagnosing lipidema compression therapy is one of the things that's consistently recommended across all guidelines on this sort of stuff. 43:35.923 --> 43:44.888 [SPEAKER_02]: 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 43:45.208 --> 43:54.115 [SPEAKER_02]: these sort of compressive garments on, which can lead to their participation in not only formal exercise, but also just like non-exercise activity. 43:54.135 --> 43:54.995 [SPEAKER_02]: There's just more active. 43:55.396 --> 44:06.584 [SPEAKER_02]: So this kind of a symptom control here, which gets them to participate in gradually increasing levels of volumes and intensities of exercise, which would ultimately also help with the payment management. 44:07.516 --> 44:17.905 [SPEAKER_00]: Yeah, must be, I mean, I'm curious from the patient's experience perspective to 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. 44:18.345 --> 44:30.255 [SPEAKER_00]: If wearing some sort of compression devices maybe mitigates that aspect, so your legs feel less heavy and you almost like subconsciously or more willing and you don't even have to think about moving around quite as much compared to when they do feel heavier. 44:30.295 --> 44:32.477 [SPEAKER_00]: That'd be interesting to hear the qualitative experience. 44:32.697 --> 44:33.557 [SPEAKER_02]: Well, that's been reported. 44:33.997 --> 44:40.039 [SPEAKER_02]: That type of report has has been mentioned and noted a number of times in papers and folks who spend a lot of time on their feet. 44:40.499 --> 44:40.659 [SPEAKER_02]: Right. 44:40.719 --> 44:42.700 [SPEAKER_02]: So just of their nurse nurses, for example. 44:42.920 --> 44:46.561 [SPEAKER_02]: Yeah, like wearing compressive socks because, you know, I feel better at the end of the day. 44:46.821 --> 44:46.941 [SPEAKER_00]: Right. 44:46.961 --> 44:53.703 [SPEAKER_02]: So then what if it gets somebody to be more active to get extra size in ten out of ten, but I'll just simple cheap safe intervention. 44:53.763 --> 44:54.823 [SPEAKER_02]: Yeah, why not we love that. 44:55.663 --> 44:59.767 [SPEAKER_02]: There should also be a psychosocial intervention or psychological intervention. 44:59.987 --> 45:23.525 [SPEAKER_02]: So, again, because these mental health conditions are so prominent, now whether it's causal or just a comorbidity as a result of developing lipidemic, 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 the medical professional to focus on psychological well-being to health folks manage this chronic 45:24.205 --> 45:25.446 [SPEAKER_02]: painful condition. 45:25.606 --> 45:30.227 [SPEAKER_02]: And the goals here if there are self-acceptance, treating other mental health issues if needed. 45:30.767 --> 45:32.528 [SPEAKER_02]: For example, PTSD is very common. 45:32.568 --> 45:37.649 [SPEAKER_02]: The individuals eating disorders is fairly common in this population as well. 45:37.909 --> 45:50.273 [SPEAKER_02]: And there are self-help groups out there, although again, some, I get, you gotta go into those things with why eyes wide open because there can be some overreliance on anecdotal sort of experiences there. 45:50.645 --> 46:06.946 [SPEAKER_00]: Yeah, only thing I would add, I think if you're, especially if you're in a clinician in a patient to evaluate patients for this type of condition is to do just that to evaluate them, not to assume that because you have may have this condition that you necessarily have a lot of psychiatric issues or mental health issues or something like that. 46:06.986 --> 46:07.607 [SPEAKER_00]: I wouldn't assume 46:08.347 --> 46:24.847 [SPEAKER_00]: That somebody presenting with what I suspect is like a demo 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 and I don't like when 46:25.688 --> 46:29.629 [SPEAKER_00]: clinicians just assume that they are likely to have those conditions because it doesn't apply. 46:30.109 --> 46:38.111 [SPEAKER_00]: And so some folks who are actually doing okay from that standpoint, they have to go out of their way to make it clear to their doctors that that's not necessarily them. 46:38.171 --> 46:46.433 [SPEAKER_00]: So, almost like, you know, there's there's some certain situations where from a medical standpoint, making certain assumptions. 46:47.375 --> 46:58.759 [SPEAKER_00]: is necessary, particularly in emergency situations, but in this type of 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 the better advice. 46:58.779 --> 47:00.419 [SPEAKER_02]: I mean, actually, I have to do the doctor thing. 47:00.559 --> 47:02.420 [SPEAKER_00]: Yes, exactly. 47:03.140 --> 47:08.582 [SPEAKER_02]: And then the last thing I wanted to talk about was liposuction here, because again, there's some 47:10.295 --> 47:16.357 [SPEAKER_02]: I want to say misinformation because that assumes like that people are maybe doing this intentionally. 47:16.417 --> 47:18.097 [SPEAKER_02]: I guess I'd be more disinformation, but whatever. 47:19.337 --> 47:24.599 [SPEAKER_02]: The issue here is that the data on liposuction in folks with lipidema is challenging to interpret. 47:24.919 --> 47:27.699 [SPEAKER_02]: Mostly because there's short-term follow-up, right? 47:27.880 --> 47:29.680 [SPEAKER_02]: So like what happens in next three months or six months? 47:29.700 --> 47:33.381 [SPEAKER_02]: That's distinctly different than what happens in three years, six years, ten years. 47:34.162 --> 47:38.726 [SPEAKER_02]: Um, they use weird assessment tools that have not been validated in this patient population. 47:39.347 --> 47:47.575 [SPEAKER_02]: And there's no like randomized controlled trial, like a sham liposuction just to see like if you if you just, you know, pretended that somebody went under the knife. 47:47.836 --> 47:48.036 [SPEAKER_02]: Sure. 47:48.456 --> 47:51.760 [SPEAKER_02]: And they were wearing compressive stockings both for those like so they didn't really know. 47:51.780 --> 47:52.580 [SPEAKER_02]: So they were blinded. 47:53.279 --> 47:58.843 [SPEAKER_02]: would their pain symptoms decrease due to the clinical theatrics of undergoing this procedure, their expectation. 47:59.383 --> 48:00.904 [SPEAKER_02]: I'd be curious, but we don't have that data. 48:01.485 --> 48:15.314 [SPEAKER_02]: 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 lipatema provided that they are weight stable. 48:17.123 --> 48:17.584 [SPEAKER_02]: say that again. 48:17.844 --> 48:27.479 [SPEAKER_02]: The data is really good on liposuction, as far as it reducing pain and cosmetically people's cosmetic goals here, if they are a weight stable. 48:28.744 --> 48:30.565 [SPEAKER_02]: The problem is that most people are not wait stable. 48:30.785 --> 48:30.925 [SPEAKER_00]: Yeah. 48:31.145 --> 48:32.506 [SPEAKER_00]: That seems like an important caveat. 48:32.706 --> 48:32.966 [SPEAKER_02]: Yeah. 48:33.286 --> 48:41.570 [SPEAKER_02]: And so the current consensus statement on this suggests that good candidates for liposuction, they would be wait stable. 48:42.431 --> 48:49.514 [SPEAKER_02]: These are also individuals who have limited mobility due to pain and or the actual physical size of their lower extremities. 48:50.215 --> 48:56.258 [SPEAKER_02]: They have persistent symptoms despite twelve months of conservative treatment. 48:56.938 --> 48:59.020 [SPEAKER_02]: and that their BMIs are less than thirty-five. 48:59.721 --> 49:08.531 [SPEAKER_02]: 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 require different sort of treatments. 49:09.492 --> 49:18.302 [SPEAKER_02]: They also may be better candidate for another procedure like metabolic bariatric surgery, which would have a bigger effect really than the liposuction and more permanent, we think. 49:18.835 --> 49:42.426 [SPEAKER_00]: 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 twenty twenty two ABMS guidelines, the American kind of society around metabolic bariatric surgery, they dropped the usual cutoff from thirty five and forty to thirty and thirty five for consideration of being eligible for metabolic bariatric surgery. 49:42.486 --> 49:46.488 [SPEAKER_00]: So greater than thirty kind of with obesity or body fat related comorbidities. 49:46.548 --> 49:48.429 [SPEAKER_00]: So again, it's possible for somebody to have both 49:49.011 --> 49:51.253 [SPEAKER_00]: obesity and lipidema. 49:51.553 --> 50:00.098 [SPEAKER_00]: And they may have consequences of that like type two diabetes, that's difficult to control or advanced osteoarthritis for various other things. 50:00.899 --> 50:05.282 [SPEAKER_00]: And they might actually be a great candidate, even if there'd be a miles a little below, thirty five necessarily. 50:05.422 --> 50:11.546 [SPEAKER_00]: Before they're BMI exceeds thirty five, and they accumulate more comorbidities and medical complications of it. 50:11.626 --> 50:16.990 [SPEAKER_00]: So that's, you know, if I'm imagining, if I were in this situation and entertaining the possibility, 50:17.390 --> 50:24.372 [SPEAKER_00]: of pursuing something like liposuction to address the both the pain and the kind of cosmetic appearance of this issue. 50:25.012 --> 50:35.874 [SPEAKER_00]: I'd be weighing that heavily against, even though they're obviously dramatically different procedures, but which one is more likely to impact not just the lipid team, but also general health and longevity and things like that. 50:36.675 --> 50:37.955 [SPEAKER_00]: So there's some trade-offs to consider. 50:38.347 --> 50:38.567 [SPEAKER_02]: Yeah. 50:39.127 --> 50:39.348 [SPEAKER_02]: Yeah. 50:39.448 --> 50:52.155 [SPEAKER_02]: So I think that's a good summary here of Lipedema, you know, just to reiterate this is a chronic medical condition we think has its origins in a genetic sort of predisposition to this condition. 50:52.355 --> 51:02.600 [SPEAKER_02]: It is symmetrical, bilateral increase in adipose tissue fat tissue in both legs spares the feet most of the time, mostly occurring in women. 51:02.860 --> 51:05.602 [SPEAKER_02]: It is responsive to both weight loss through 51:06.102 --> 51:12.988 [SPEAKER_02]: If it's like style alone, if it's metabolic bariatric surgery, if it's that combined with the pharmaceutical interventions and also exercise seems to be beneficial. 51:13.268 --> 51:29.021 [SPEAKER_02]: There are other therapies that are recommending, including compressive therapy, psychosocial, psychological sort of support and evaluation, liposuction, maybe a reasonable treatment depending on the patient and the preferences and other factors affecting them. 51:30.638 --> 51:34.322 [SPEAKER_02]: But overall, I just find this to be a very challenging sort of condition. 51:34.342 --> 51:36.044 [SPEAKER_02]: Not only for diagnosis, but also management. 51:36.164 --> 51:41.669 [SPEAKER_02]: And I think I don't have a good explanation for why it's so challenging other than it's just like if people does not care. 51:42.382 --> 51:42.602 [SPEAKER_02]: You know? 51:42.982 --> 51:52.384 [SPEAKER_00]: 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. 51:52.424 --> 51:53.944 [SPEAKER_00]: So it's also under research heavily. 51:54.484 --> 51:56.645 [SPEAKER_00]: So, you know, that's a tough deal. 51:56.925 --> 52:00.345 [SPEAKER_00]: You think RFK juniors got a, it cares a lot about lipidema. 52:00.825 --> 52:02.746 [SPEAKER_02]: I do not think he cares a lot about the skittition. 52:03.146 --> 52:06.386 [SPEAKER_02]: I agree because, yeah, you would probably view it as just a willpower thing. 52:06.426 --> 52:08.307 [SPEAKER_02]: So just, you know, let's focus on willpower. 52:08.827 --> 52:10.207 [SPEAKER_02]: We'll say that for a political podcast. 52:11.507 --> 52:12.268 [SPEAKER_02]: Barbell politics. 52:13.268 --> 52:19.350 [SPEAKER_02]: No, thank you so much to Dr. Austin Baraki for joining us here on the Barbell Medicine podcast where we talked about like a team up. 52:19.370 --> 52:22.071 [SPEAKER_02]: Before you guys go anywhere, please leave us a five star rating and a review. 52:22.391 --> 52:24.192 [SPEAKER_02]: It really helps drive traffic to our podcast. 52:24.252 --> 52:28.554 [SPEAKER_02]: We can keep bringing you all the latest nuance and health and fitness from everyone here at Barbell Medicine. 52:28.574 --> 52:29.554 [SPEAKER_02]: I'm Dr. Jordan Faganbaum. 52:29.594 --> 52:33.016 [SPEAKER_02]: We'll catch you next week and every week right here on the Barbell Medicine podcast.