Showing posts with label morbidly obese. Show all posts
Showing posts with label morbidly obese. Show all posts

Saturday, January 12, 2019

Induction: Don't Break The Waters Early

Amnihooks, which are used to artificially break a woman's waters

New research (Pasko 2018) suggests that when care providers induce high BMI women, they should NOT break the waters in early labor (early amniotomy), especially in first-time mothers.

Breaking the waters early is commonly done to speed up labor. Sometimes it is done to place an internal monitor to monitor the baby more easily, but usually it is used to intensify contractions and shorten labor. Caregivers assume that this will help obese women avoid a cesarean.

However, the results from this new study suggest that early amniotomy actually increases the risk for a cesarean instead.

Study Details

In this retrospective cohort study, women with Class III "obesity" (body mass index ≥40 kg/m2) who were being induced  (n=285) were placed into two groups.

The first group (n=107) received early amniotomy before 4 cm dilation, and the other group (n=178) received late amniotomy.

The group who received early amniotomy had double the cesarean risk of those who did received later amniotomy.

In first-time (nulliparous) mothers, the risk for cesarean was tripled with early amniotomy. 

The length of labor was not shortened in either group. So the whole justification for using early amniotomy (shorter labor, fewer cesareans) for obese women was irrelevant.

An older study (Sheiner 2000) which examined induction by early amniotomy concluded:
In order to decrease the CS rates, induction should probably start with cervical ripening techniques in order to improve the Bishop scores.
Bishop Scores are a measure of how ripe and ready for labor the cervix is. Inductions on an unripe cervix are more likely to fail and result in cesarean, especially in first-time moms. Bishop scores tend to be lower at the start of inductions in women of size, which is probably an important factor in higher weight women's induction failures. 

Women of size also tend to have longer labors and generally take longer in latent (early) labor before reaching active labor. Yet despite this, research shows that early amniotomy is used more often in higher weight women. This needs to change.

How can early amniotomy (also known as Artificial Rupture of Membranes or early AROM) affect labor? When the water is broken, the cushioning around the baby is removed. Labor becomes much more painful, and there is risk for infection. The baby may be more likely to experience an abnormal heart rate (distress). If the baby is not well-positioned when AROM occurs, then the baby can become stuck in that position and have difficult getting out (labor dystocia). These factors can add up and result in a cesarean.

The take-home message from this study on high BMI women is obvious: Avoid having your waters broken before active labor begins (now defined as at least 6 cm dilation). This is especially important if you are a first-time mother. 

Of course, parents have to remain flexible in labor; plans may need to change. For example, if baby may be in trouble and external monitoring is not working well, then breaking the water sooner to place an internal monitor may make sense. But most of the time, amniotomy should not be done early in labor, especially in obese first-time mothers.

Induction Hints

It is best to await spontaneous labor whenever possible, so always question whether an induction is truly necessary. However, it's a hard truth that sometimes induction of labor does become medically necessary. If so, there are some lessons from research that may lessen your risk for cesarean. Most apply to women of all sizes but may be particularly relevant for higher weight women.

Ask your provider about your Bishop Score; if your cervix isn't ripe (Bishop score <5), ask if the induction can be delayed. If it cannot be delayed, ask for techniques to help ripen the cervix before pitocin is started and realize that you may need more time to reach active labor. Some research suggests that Foley catheter or prostaglandin (PGE2) inductions may be more effective in women of size than misoprostol (Cytotec).

Women of size may also need a larger dose of pitocin to keep an induced labor going strong, but this must be done cautiously because too much pitocin can send the baby into fetal distress. Wait and see how you and baby respond before increasing the dosage and go slowly with any adjustments.

Be sure you have a care provider who understands that latent labor tends to take longer in higher weight women and will give you plenty of time. Many cesareans in women of size are done before active labor, and many could probably be prevented if caregivers were more patient and waited longer before moving to a cesarean.

Be sure your baby is in an optimal position for birth before the induction if possible. Chiropractic care may help align the pelvis and maximize the space for an easier birth. If the baby is posterior (facing your front) in labor, ask your caregiver for manual rotation, which clearly reduces the risk for cesarean in several studies.

Maintain your mobility as much as possible and don't get stuck in bed on your back. Make gravity work for you. Upright positions reduce the length of labor and the risk for cesarean. Special positions like hands and knees or an exaggerated Sims position may help malpositioned babies turn more easily. You can read more aboutvarious labor and birth positions here.

As discussed, don't let the caregivers break the waters until you are well into active labor. If possible, let the waters break on their own. Keeping the waters intact as long as possible can help a malpositioned baby turn more easily.

Hire a doula to give professional labor support. One study found a cesarean rate of 13.4% in a group of first-time mothers with doulas, whereas the cesarean rate in the group without doulas was 25%. The difference was even more marked in those whose labors were induced; the group with doulas had a cesarean rate of 12.5%, vs. a 58.8% rate in those without doulas.

These ideas should improve your chances of a normal vaginal birth with an induction. Of course there are no guarantees, but rest assured that with enough time and patience, a reasonably ripe cervix, a well-positioned baby, and good support, many inductions in women of size can result in vaginal births.



Reference

Am J Perinatol. 2018 Nov 5. doi: 10.1055/s-0038-1675331. [Epub ahead of print] Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. Pasko DN, Miller KM, Jauk VC, Subramaniam A.  PMID: 30396229 
OBJECTIVE: We sought to evaluate differences in pregnancy outcomes following early amniotomy in women with class III obesity (body mass index ≥40 kg/m2) undergoing induction of labor. STUDY DESIGN: This is a retrospective cohort study of women with class III obesity undergoing term induction of labor from January 2007 to February 2013. Early amniotomy was defined as artificial membrane rupture at less than 4 cm cervical dilation. The primary outcome was cesarean delivery. Secondary outcomes included length of labor, a maternal morbidity composite, and a neonatal morbidity composite. A subgroup analysis examined the effect of parity. Multivariable logistic regression was used to adjust for covariates. RESULTS: Of 285 women meeting inclusion criteria, 107 (37.5%) underwent early amniotomy and 178 (62.5%) underwent late amniotomy. Early amniotomy was associated with cesarean delivery after multivariable adjustments (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.21-3.47). There were no significant differences in length of labor or maternal and neonatal morbidity between groups. When stratified by parity, early amniotomy was associated with increased cesarean delivery (aOR, 3.10; 95% CI, 1.47-6.58) only in nulliparous women. CONCLUSION: Early amniotomy among class III obese women, especially nulliparous women, undergoing labor induction may be associated with an increased risk of cesarean delivery.


Friday, June 29, 2018

Lipedema: My Story


June is Lipedema Awareness Month. In lipedema, a fat storage disorder, an abnormal accumulation of fat develops in the legs and lower body, sometimes extending to the arms and other body parts as well. It is sometimes known as "painful fat syndrome" or "big legs syndrome." Although no one knows its true incidence, it has been estimated to affect up to 11% of women.

To raise awareness about this condition, we have been doing an periodic series about lipedema. Here is what we have covered so far:
Today, I share some of my own story of dealing with lipedema and how it has influenced other health challenges.

My Story

Lipedema Posters from LASS, www.lass.org.au,
Lipoedema Australia Support Society
Like the woman above, I too have lipedema and went undiagnosed for many years, which probably made my lipedema worse. This is why I try to raise awareness of this condition. Far too many people of size have lipedema and aren't aware of it, thus missing out on possible treatments for it. I was one of them.

I only learned about lipedema when I was around 50 ─ but I found out about it from the internet, not from any doctor. I fit the classic profile of lipedema perfectly, with all the symptoms and nearly all the complications of it, but no care provider had EVER mentioned lipedema to me. No care provider had ever once thought to look more deeply into my inability to lose weight long-term or to question whether my abnormally heavy legs might mean something. They just chalked it up to bad habits and tried to pressure me to continue to diet, despite its many past failures.

Once I learned about lipedema, all kinds of light bulbs went off in my head. A-ha! So that's why I had that funny shape! So that's why I gained so much weight as a young adult, despite workng incredibly hard to try and lose weight. So that's why I had all those symptoms!

But even once I learned about lipedema, I didn't do much about it. I didn't think that there were many treatment options, so I didn't really bring it up with my care providers. I was more focused on my PCOS (Polycystic Ovarian Syndrome) and hypothyroidism, both of which seemed more treatable. But while treating those did help my overall health, it didn't address my lipedema.

When I finally did bring up lipedema at the doctor's, I had to educate my provider about it because she had never even HEARD of it. Once she read the articles I gave her, she agreed I definitely fit the classic pattern but was at a loss for what to do about it. It's in my medical record now as a sub-note under "obesity" but because there is no official international diagnostic code for lipedema yet (despite it having been known about since 1940) that's all she can really do. Lack of insurance coverage for lipedema treatment is a major barrier and the first step is an official diagnostic code for it.

I'm in Stage 3 lipedema, with the start of lipo-lymphedema (stage 4). I have the Type III classic "pantaloon" shape of my legs, complete with the shouldered ankles and fat pads by the knees, and the lipedema is now in my abdomen and my upper arms as well. I look at lot like the lady in the poster above, but with more cankles and less knees.

Sadly, my eldest daughter seems to have inherited my lipedema; she had the big gain in early adulthood too and is already Stage 2. I'm worried about what will happen with her in the future. On the other hand, my youngest daughter shows no signs of lipedema at all, so I'm hoping she avoided this genetic minefield. Time will tell as she's just a young teenager now.

In the hope that it will help others with lipedema, here is my lipedema story. I've tried to be detailed in case others find those details helpful.

Childhood

My childhood shape was very much like the pear above, except with thicker thighs. My lower legs and arms were mostly unaffected. That came later.

I am adopted, so I have only limited family medical history available to me. From what little I do know, it doesn't seem like my birth mother had significant lipedema at the time I was born. She did have other medical issues but apparently not lipedema. I would like to know if there was any history of large legs on either side of my biological family but so far have not been able to discover this information.

I was always "chubby" and pear-shaped to some degree as a child, even while eating the same healthy foods as my thin adoptive family. Although I am not athletic, I still rode my bike, played in the woods, swam competitively, took several years of dance and gymnastics, and played football and baseball with the neighborhood boys. While I preferred reading to running, I was a reasonably active kid. My chubbiness had nothing to do with poor eating habits or lack of exercise.

When I took gymnastics, the teacher was quite amazed at how limber I was, especially my back. I was much more limber than the other girls. I was able to do a no-handed back bend and pick up a cup off the floor with my teeth; no one else could. Now I realize that this was probably a sign of hypermobility, something many people with lipedema have. I was not double-jointed, but I was definitely more limber than most by far.

My adoptive mother was always bothered by my weight. She felt it was a negative reflection on her, and people would assume she was feeding me junk food. Being naturally quite thin, she simply didn't understand how I could be chubby, and she was afraid of how it would affect me. She was of the generation where a girl's looks were everything; she was afraid I'd never find a man, which in her worldview was the real measure of a woman's worth.

She wanted to put me on a diet at 5 years old but the doctor wouldn't let her. He just encouraged her to make me be as active as possible, so she was always booting me out the door to play. Didn't make me thin. When I was nine, we moved to a new town and the new doctor agreed to put me on a diet. It was a "healthy" diet, nothing radical, just mildly hypocaloric. I did lose some weight for a little while ─ until it came back, as it usually does. (And not because I slacked off.) So then I dieted again, and again the weight came back. So then we did it again, only this time with a lower calorie count, etc.

Thus began my many years of yo-yo dieting. I dieted off and on (mostly on) from the age of 9. Generally speaking, each diet was more rigorous as I got more and more desperate to lose weight.

Teens

Image by Sarah Bishop
Once I hit puberty at about 13, my weight increased quite a bit. Most of the gain was in my hips and legs; I became even more pear-shaped. I was smaller on top than on the bottom, but I did not have the extreme disproportion that some lipedema women have.

I had great difficulty buying regular pants because my waist was so much smaller than my hips. This is typical of women with lipedema. My mom made many of my clothes for me when I was younger in order to give me elastic waists. It was the only way to get pants that didn't gap hugely at the waist.

I wasn't extremely fat, though I was certainly perceived as fat by those around me. I can remember people staring at or remarking on my legs as a teen. One boy who was interested in me said, "Well, now I can see why you don't wear shorts!" (Nope, he most certainly did not become my boyfriend.)

When I was 13, my adoptive father had a heart attack; heart problems ran strongly in his family. Although we had always eaten healthy, our diet got even more rigid after that. We ate low-fat, semi-vegetarian, and rarely had sugar ─ yet I still gained weight.

So I continued to diet off and on via calorie restriction and carb restriction. My legs remained heavy even when the rest of me lost weight, but frankly I never become a "normal" size no matter what I did, and the weight always came back with extra. 

I started skipping periods occasionally due to PCOS but the PCOS went undiagnosed. Around age 15-16 I did some serious time with Weight Watchers (WW) and did lose a bit of weight, but not not nearly what was expected for the amount of time I was on the program and I never got to a "normal" BMI. Despite the weight loss, I still had a definite pear-shape and my periods stayed irregular.

I remember being treated suspiciously by the Weight Watcher leaders because I wasn't losing "enough" weight; they suspected me of lying about my intake. But I was very strict and carried a scale with me everywhere to weigh my food or carried my own healthy snacks with me when I went out in an effort to strictly control my calories. Still, the weight came back. Weight Watcher weigh-ins became a nightmare. I grew to really loathe weigh-ins because of the judgment I received at them.

I got more and more desperate and began to develop some eating-disordered behaviors ─ nothing major, but still not healthy, mainly trying to manipulate weigh-in results. I eventually quit WW in disgust because I wasn't losing weight anymore despite my most dedicated efforts, and because I was concerned the neurotic food behaviors and attitudes of the people at meetings were encouraging me to become more eating-disordered. Far from being "healthy," it felt like a very unhealthy place to be. I also tried Overeaters Anonymous, but was even more put off by that program because the extreme eating behaviors the other members described did not fit my experience. Again, it felt like a very emotionally unhealthy place to be.

Late Teens and Early 20s



During my senior year of high school, I started gaining weight like crazy ─ all while dieting and getting plenty of exercise, including biking, cross-country skiing, and even climbing a mountain, but none of that made any difference.

The weight gain accelerated in college. I took a Fitness Class in an effort to stem the weight gain. I was jogging, running stairs, biking, swimming, and lifting weights. I remember the coach criticizing my "HUGE legs" (his words, with that amount of emphasis). I gained 25 lbs. in a semester during that Fitness class, despite being on Weight Watchers again and getting tremendous amounts of exercise during the class. I'm pretty sure the coach thought I was binge eating in a closet somewhere but I wasn't. I was simply in the middle of a significant lipedema "flare."

My parents were horrified by my large weight gain. I moved out of the dorm so I could avoid "fattening dorm food" (even though my dorm-mates ate the same food and were skinny). I saw a number of doctors over the years, trying to figure out the weight gain, but found no answers. They noted that my thyroid TSH labs were borderline but because they were still within the "normal" range, they basically just told me to eat less and exercise more.

Although I had always been a healthy eater as a kid, I started developing more unhealthy eating patterns in response to all of this. I began alternating between restrictive diets and overindulging in "unhealthy" foods (though I was never a true binge eater). In desperation, I went back to WW several times during my college years, but found little weight loss and lots of food neurosis. Again, I manipulated for weigh-ins. I was concerned about what I was starting to do but felt such pressure at those weigh-ins. The basic food plan wasn't bad but the attitudes around food and weight in the WW meetings were extremely toxic. I quit to save my own sanity and because I was concerned I was headed for an eating disorder. I saw women around me in college with true eating disorders and how difficult that was. I realized I was headed in that direction if I didn't stop, so I did.

Over the course of several years, despite all the dieting and exercise, I gained about 100 pounds total, most of it in the lower body. I had a terrible time finding clothes to wear; there was no internet then and my college was in a fairly small town. Chain stores and Goodwill had nothing in my size. I lived in men's overalls because that's all I could find to fit.

It was hard to be positive about my body, but I was fortunate to have a boyfriend who loved me as I was. Being away from my mother's well-meaning but neurotic weight focus also helped boost my self-esteem and confidence. I developed a can-do attitude, worked hard for top grades, and didn't let me weight keep me from what I wanted to do.

Still, I was worried what my weight would do to my health. In desperation, eventually I joined a special medical weight loss clinic, following a low-calorie ketogenic diet. I lived on 500 CALORIES A DAY, far below starvation levels, in ketosis, for SIX MONTHS during my senior year of college. (This is slightly lower than the caloric intake of the Dutch famine victims in World War II, for about the same amount of time, and the Dutch famine is considered a severe famine exposure). I lost 50 lbs., but still had fat legs, hips, and arms, and never got remotely close to a "normal" size. By the end of the 6 months, I slowly began gaining weight back ─ while on 500 calories a day.  And I still wasn't thin enough to suit my mother.

That starvation diet was a real wake-up call. I saw how foolish such an extreme approach was and how awful I felt, so I stopped the program. That program made me realize that something else HAD to be going on physiologically and that it wasn't just about my intake and output. I quit blaming myself. I went back to eating normally. It didn't take long before I returned to my original weight plus a little more ─ but with much more abdominal fat than I'd had before. That's when the lipedema really began affecting my abdomen too.

In hindsight, I think I had a "perfect storm" combination of PCOS, hypothyroidism, and lipedema all hit me at once, and this triple-whammy caused the massive weight gain. I had gained about 100 lbs. despite multiple bouts of Weight Watchers, fitness classes, a starvation diet, and a million other things to try to stop the weight gain. Every doctor I consulted told me I just needed to eat less and exercise more; that it was just a matter of adjusting the math of intake vs. output, and having strong willpower. One endocrinologist I went to for thyroid testing told me that I was "just looking for an excuse for being fat."

I knew there had to be more to the story but eventually gave up going to doctors because my concerns weren't taken seriously and I was tired of the weight harassment. I just tried to live a reasonable life and accepted that I would always be fat.

Mid-20s to Early 30s


Eventually my weight stabilized in my mid-20s. I stopped dieting, which helped stop the weight yo-yos and probably also stopped a full-blown eating disorder from developing. Leaving dieting certainly boosted my self-esteem and improved my mental health!

Of course, I still encountered weight bias in my career and in the world. I was "morbidly obese" and people didn't hesitate to let me know it. I had a boss verbally pressure me to lose weight, and it came up in my job performance reviews...but only unofficially, so he didn't get into trouble. Another boss looked for a replacement for me because I wasn't "pretty enough" (code for too fat), as if physical appearance had anything to do with competency in my field. Fortunately I was very skilled and kept the job.

It was frustrating to have all kinds of assumptions made about me based on my size, but I didn't let it hold me back. I got married, achieved in my career, traveled a lot, acted on stage, and participated in many fun activities. I lived my life and was happy.

In my late 20s, I finally found a doctor who was willing to consider my symptoms of subclinical hypothyroidism. We did a trial of thyroid meds, which improved my life greatly. I stopped skipping periods and my skin issues improved. I had other PCOS symptoms that didn't abate but the thyroid meds blunted the worst of them. I felt like a reasonably normal human being again. I felt SO much better once I started on the thyroid meds, even though it made little difference to my weight or body size.

My lipedema did worsen in my 20s. My legs got larger, my arms got larger, and weirdly, my bust also got suddenly larger despite a stable weight. By my late 20s, it was quite hard to find clothes that worked for my body (large bust, small waist, very large hips).

My legs were pretty heavy by my 30s; I couldn't wear boots or knee-high socks anymore. It was hard to find clothes that fit me, even with big-city clothing stores. Still, my legs didn't interfere with my life too much. I had no mobility issues and I was able to be active. I wasn't any kind of athlete but took periodic aerobics or yoga classes and did a lot of folk dancing, walking, dancing in plays, and just generally enjoyed my life.

Mid-30s and early 40s; Four Pregnancies

Poster from LASS (see above)
My husband and I decided to start a family in our 30s. I was lucky to have the ovulatory PCOS phenotype, so once my thyroid issues were treated, I never had any trouble with my cycles again and had no trouble getting pregnant, even into my 40s. I'm so glad we waited to try until after my thyroid issues were addressed!

I had four pregnancies between age 33 and 43, resulting in 2 girls and 2 boys. The first pregnancy was rough because there was no information on pregnancy at a larger size available then, and I encountered a lot of size bias in that pregnancy. I had a nightmare cesarean after a long hard induction and developed PTSD. Breastfeeding was rough at first because I got poor advice. Afterwards, I spent a lot of time educating myself about pregnancy and breastfeeding so I wouldn't go through anything like that again, and started my website to help other large moms get information and empowerment.

I had much better experiences with my later pregnancies. I did have another cesarean after a long hard labor with #2, but in some ways it was healing, even if it wasn't the birth I wanted. With my last 2 children, I had VBACs (Vaginal Births After Cesarean), and they went a long way towards restoring my faith in my body. So did breastfeeding all four of my children long-term.

Some women with lipedema find that pregnancy and birth worsen the lipedema. For the most part, my experiences were normal and I didn't experience the severe issues that some women with lipedema do in pregnancy. I didn't gain much weight and I didn't develop any serious complications.

However, I did gain more lipedemic fat in my abdomen with each pregnancy and I really started to feel the fat nodules under the skin there. This wasn't the result of pregnancy weight gain; I gained less than the weight of my babies with each pregnancy and ended all four pregnancies at about the same weight I started them. But despite being the same weight, I had quite a bit more abdominal fat afterwards. Classic lipedema.

Some women with lipedema find that pregnancy and birth result in secondary lymphedema. I did find I experienced severe swelling after the births of #1 and #4, but not the others. Why I had it with only some births but not others is not clear but it's interesting that I only experienced it with my daughters. Of course, birth interventions can also influence edema. It's my opinion that it takes a combination of factors to cause problems.

One major negative thing was that I had a LOT of back pain and joint issues (pubic symphysis and sacro-iliac joint issues) in my pregnancies. I had a lot of pain until I finally started seeing a chiropractor in my 3rd pregnancy. Since lipedema is associated with joint laxity and hypermobility, that (plus my history of car accidents) may well have been the source of my joint issues.

Seeing a chiropractor highly trained in pregnancy starting with #3 was extremely helpful in getting my back and pelvis aligned. It reduced my discomfort tremendously and helped the baby be in an easier position for birth. I strongly believe it was the reason I was able to have normal vaginal births (VBACs) with my last two children but not my first two. My last two babies were better-positioned and far easier to birth and I really credit that to the chiropractic care.

Despite being nearly 43 and "morbidly obese," my last pregnancy was my best. Even the edema and lipedema flare I had postpartum was a relatively small blip on the radar. Don't let the fact that some women with lipedema experience difficult pregnancies put you off having a baby; some women with lipedema do just fine in pregnancy. It's probably sensible to try to avoid the big interventions like inductions and cesareans whenever possible because they predispose to edema and complications afterwards. Remember that lipedemic bodies can give birth just fine naturally with a truly size-friendly provider.

Personally, I did not find that lipedema affected my pregnancies very strongly; my biggest difficulties were with weight bias/over-intervention by providers, and in dealing with hypermobile joints during pregnancy. However, I did find that pregnancy increased my abdominal lipedemic fat every time, despite almost no weight gain, and I did experience significant temporary edema after two of my births.

Perimenopause and Menopause


As I transitioned into middle age, I did find that my leg size increased quite a bit, especially as I went through perimenopause and menopause from my mid-40s to mid-50s.

More than simply a size change, the shape of my legs changed. I developed major fat pads and "folds" just under my knees, and I got some major-league "cankles" (calf-ankles). My arms have also gotten much larger now. I now have a truly significant amount of fat on my hips, abdomen, legs, and arms, and people really do stare. Although I am pretty at peace with my body in general, it's not always easy.

Clothing-wise, lipedema has made aging more challenging. Finding good clothing is always hit-and-miss due to my unique proportions. Cold weather outer gear and rain gear have been my biggest challenges, as I've written about before. I often have to buy men's gear, which goes to larger sizes than women's sizes but it is geared towards a big belly and no hips, which is not my shape. Still, it's better than nothing. I have found good coats in my size through Columbia Sportswear but I have yet to find a pair of rain boots, rain pants, or snow pants which really work well for me.

In summer, I do wear shorts and go swimming and the heck with anyone who doesn't like it. Most of the rest of the year I wear pants, the comfortable kind in cotton-and-spandex stretch fabric. I found my tolerance for restrictive fabric has diminished. Now, I mostly care about whether my clothes are comfortable. I wear pants or long skirts at work or when speaking to help others focus on me instead of staring at my legs. It's hard enough for people in our society to take fat people seriously; it's even harder when you have lipedemic legs. So in certain situations, I do cover my legs and arms to be taken more seriously, but that doesn't mean I always dress that way.

After some car accidents in my late 40s, I developed significant knee problems. I'm sure my weight didn't help the injuries, but I'd been at the same weight for many years without any problems so it wasn't all about my weight. Yet the orthopedic surgeon I consulted told me my knee pain could only have been caused by arthritis due to weight, despite an x-ray showing very little arthritis the year before the accident. He refused to do an MRI, saying it was pure coincidence that the pain developed after the accident. He was unwilling to treat my knee issues with anything other than weight loss or injections. We compromised on physical therapy but it didn't help. I haven't been back to an orthopedist since. I should have my knees replaced but am reluctant to risk having surgery cause a lipedema flare.

The difficulty in finding a doctor who doesn't blame everything on weight is a source of continuing major frustration to me, especially as I age. It's hard to be taken seriously as a person of size when you are young: it's even harder as a middle-aged woman. We are virtually invisible in society and especially in medicine.

Cancer


As if that wasn't enough, it gets harder. My lipedema was made worse by the fact that I was diagnosed with cancer in my mid-50s. Not any of the cancers that might be associated with weight, but lung cancer, a type of cancer that is completely unassociated with size. Talk about a shocker. I never smoked or had any other risk factors. The only possible risk was perhaps genetic ─ my birth father died of lung cancer in his late 50s ─ but doctors tell me this type of cancer is not directly inherited. Who knows why I got it.

My cancer was largely silent at first. I had very few major symptoms until it was advanced. The subtle early symptoms were things like breathlessness, some hoarseness, lack of endurance, and weak legs. I blamed it on being anemic and getting out of shape. I kept trying to get back into shape but just could not sustain my exercise program because it made me so fatigued. Yet nothing felt really alarming.

The first symptom that was really obvious and alarming was large lumps under my skin ─ subcutaneous tumors. At first I assumed they were lipedema nodules, but when they started appearing in areas not normally affected by lipedema (spine and shoulder) I thought they were lipomas (fatty benign tumors) or perhaps Dercum's Disease, which some patients get in addition to lipedema. However, the lumps on my body were not painful, unlike Dercum's Disease, so it didn't fit perfectly. I made an appointment to see a doctor but for various reasons the appointment got put off.

Eventually I developed severe respiratory symptoms. We thought it was pneumonia. I didn't see my normal care provider due to circumstances, and the other doctor didn't take it seriously. He should have done a chest X-ray but he didn't. He said it was just a sinus infection. We tried antibiotics but they didn't help. I kept going back to the doctor multiple times and he basically told me to tough it out and I probably just had asthma. (Cause you know, fat.) Due to all these delays, by the time my cancer was diagnosed, it had spread all over my body.

How did lipedema affect my cancer diagnosis? It certainly made it more difficult to figure out because we thought the subcutaneous tumors were part of lipedema or Dercum's. And of course the weight that goes with lipedema meant that my doctor did not take my respiratory symptoms, weakness, and fatigue seriously, even though they were very serious and debilitating. By the time my cancer was diagnosed, I was nearly dead.

I am lucky that my particular mutation of lung cancer does have some treatments available, and that means my prognosis is better than some. Many lung cancer patients die within the first year and I have already surpassed that. My targeted therapy treatments brought me back to life and made me mostly functional again. I'm not back to normal but I'm a lot better than I was! However, I am unlucky in that my cancer is not curable. It will likely kill me but the treatments are changing so rapidly that it's difficult to predict the future.

The cancer treatments and related complications have triggered the development of lipo-lymphedema ─ lymphedema on top of  the lipedema. This has been difficult. One of the side effects of my first cancer medication was severe ankle and foot edema. Although my feet had always been spared before (one of the defining aspects of lipedema), suddenly now I had massively swollen feet as well as legs. Eventually I changed medications and my foot swelling went away, but I still struggle with leg lymphedema.

I have to be honest; the increase in leg size has been quite challenging. It makes it harder to get around and it's very tiring. Cancer often involves muscle wasting; a lot of food energy is diverted to the tumors and the cancer starts cannibalizing your own muscle for additional energy. To be a large person with lipedema and then experience muscle wasting means that mobility becomes a real issue. After a stay in Intensive Care, I had trouble walking for a while. I had to go to rehab and get physical therapy before I could return to my home. Now I am much improved, but walking is still definitely exhausting and I don't go all that far. I miss taking a nice walk but am trying to build that up to that again.

Dealing with Lipedema


Dealing with lipedema has not been easy over the years, but has definitely gotten more challenging as I have aged and other health challenges have arisen. When I was younger, it was more of an aesthetic problem and a problem with finding clothing than a real interference in my life. It didn't affect my mobility much and I did most things I wanted to do. However, lipedema plus cancer has now affected my mobility and I find that very difficult, though I try not to let it get me too down. I work hard not to let lipedema or cancer define my life, but it's not easy some days.

The things that I have not found helpful in my lipedema journey are dieting of any kind and rigid attitudes about food. I don't follow either an anti-inflammatory diet nor a ketogenic diet; these approaches are simply somebody's guess at a treatment; there is absolutely NO proof that they help. At this point, nobody's even tested them so it bothers me to see them talked about in lipedema circles as if they are a proven treatment. They're not.

Unfortunately, many people in the lipedema community are still stuck in the dieting mentality and weight loss emphasis. Food restriction is a strong thread in many lipedema and medical organizations' guidelines. That is very off-putting to many people of size who would otherwise involve themselves in the lipedema community. Many care providers try to be understanding about weight issues, but the one thing most cannot understand is clients not actively trying to lose weight. They have been taught the "good fatty/bad fatty" paradigm; you can be fat, but that's no excuse for not continuing to try to lose weight. But for me, trying to lose even the 5-10% doctors recommend means playing Russian Roulette with my body because weight loss always ends in a rebound for me. Furthermore, I refuse to be a famine victim anymore. I'm done trying to starve myself.

Many women with lipedema, especially the more severe cases, choose weight loss surgery to try and cope with the physical effects of so much weight. This is a personal decision made by each woman and I am not here to judge it. However, from what I've seen, I don't believe it's very effective long-term for lipedema. Weight loss is mostly from other parts of the body and only minimally from lipedemic areas, and significant regain is very common after a few years. Personally, I am not interested in weight loss surgery of any kind because I have seen too many people with bad side effects after a few years. Lipedema is bad enough without adding malnutrition issues. But that's my choice; everyone gets to make their own choices about it.

Of course, we don't want to add to our lipedema by being excessive. I try to be sensible about carb intake and not over-indulge, but neither do I abstain from carbs, including sugar. I just try to be reasonable. My motto is everything in moderation (including moderation!). I try to avoid getting neurotic over food or making "good food/bad food" judgments; that is eating-disordered thinking. Some food is healthier for you than others but that doesn't make you a better person for eating it, nor will it make you skinny. I hear friends trotting out the usual "it's-a-lifestyle-change" cliché but if it eliminates major food groups or is highly restrictive, it's still a diet. Food Police moralism isn't helpful. Food is just food; simply be sensible about it.

I try to follow Health At Every Size® (HAES) paradigm instead of a weight-centric one. HAES is a health approach that de-emphasizes the scale, restrictive eating, and punitive exercise; it encourages intuitive eating and enjoyable movement. I aim for weight stability and reasonable eating habits, and use lab results to guide my health and nutrition decisions. I find my weight stays reasonably stable with that approach.

The cancer has made nutrition more challenging because the meds change the sense of taste and food is often very unappealing. Muscle wasting and malnourishment from cancer is real even for fat people, an irony which is not lost on me. My oncologist has emphasized the importance of eating and getting enough calories, even if they are not "perfect" nutrition. It's hard to let go of all the pressure from people to eat this or avoid that to "fix" my cancer, but my doctor says it's more important to just eat. Your body needs energy to deal with the cancer.

The care practices I personally have found most helpful in my lipedema journey include chiropractic care, medical massage, and complete decongestive therapy. The chiropractic care and massage helps address the hypermobility problems and muscle tightness than can occur. After I developed lipo-lymphedema from the cancer treatments, I found that Manual Lymph Drainage (MLD) and compression were immensely helpful in preventing some of the skin complications. At one point in cancer treatment, my legs had such severe swelling, my skin cracked and leaked lymph fluid. I developed a mild cellulitis infection, which we were fortunately able to nip in the bud with antibiotics. I've had to become much more careful about caring for my legs and keeping down the swelling. With MLD and compression, they are doing okay.

If I had unlimited money and no cancer, I would pursue specialized liposuction for the lipedema; it has to be done by specially trained doctors. Proper compression afterwards is critical. Research so far shows this type of liposuction to be quite helpful for many people. Sadly, most insurance will not cover this and my budget does not allow it, but it may be a valid choice for some people with lipedema.

Emotionally, I find it difficult to deal with the judgment heaped on people of size. When you say that you have lipedema, people think you are just making excuses. That I find really frustrating, especially when it comes from friends. I know some think I could lose weight if I tried harder, and that hurts. But I can't control what other people think, and anti-fat bias is so prevalent in our society it's no surprise they think that way. I try not to let those biases get in the way of friendship as long as they are respectful.

While I can't honestly say I'm thrilled with the appearance of my legs or arms, I don't let it bother me too much because there's realistically very little I can do about it. I don't like being stared at, but I try to see it as the other person's issue, not mine. Remember that how people react to you often has more to do with their own fears and insecurities, not yours. Let condemnation and judgment roll off of you.

I personally have been fortunate to have never struggled with depression the way that many people with lipedema have. That doesn't mean that dealing with lipedema and with cancer has not been frustrating or upsetting; it most certainly has! But depression is not one of my issues and I know that's lucky.

However, anger is one of my issues. Sometimes it makes me SO angry that I've been saddled with PCOS and hypothyroidism and lipedema. Talk about a genetic triple whammy! That is incredibly frustrating. And now cancer on top of that?!??! So incredibly unfair!!!!!!!

Having all of those conditions just sucks and I do sometimes indulge in the "Why me?" game. Sometimes I throw myself a really good pity party and let myself wallow in it for a while. I think that's reasonable and healthy ─ after all, having these conditions DOES suck and it is TOTALLY unfair. It's important to acknowledge and mourn your challenges and let yourself be angry. But spending too much time in anger is not healthy either; I don't want it to keep me from experiencing the positive things in life. So I pick myself up, brush off the negativity, and remind myself to count the blessings I do have. That helps counterbalance my pity party days.

Being adopted has added to my emotional frustration; I would really like to know more about my birth parents' genetic heritage so I could see how genetic any of this really is. I know there is an extremely strong history of diabetes and autoimmune disease on my birth mother's side, which leads me to suspect an autoimmune component to lipedema. However, it's been difficult to get more detailed information. I know there's a strong history of cancer on my birth father's side, and that he died of lung cancer at about the same age as I am now. However, there's no way to know if it's the same type of lung cancer or not, and we'll never know. That's a difficult burden, because I don't know how concerned to be for my children.

I try to remind myself that I also have good genes that balance these unfortunate ones, and I hope I passed on those good genes to my children. I try to remember the blessings I did inherit. Of course I have worries about my lipedema. How could I not? But now they've been supplanted by bigger worries, namely cancer. In the long run, lipedema is small potatoes compared to cancer. So while we have every right to be upset about our lipedema, remember to keep it in perspective. There are other challenges out there too. Keep it all in perspective.

Some days it's hard to be positive but mostly I look at my children and my spouse and feel blessed.

Final Thoughts


To summarize, I believe I've had lipedema my whole life, to one degree or another. I was never a "normal" size and I always had a pear shape, even as a young child. Puberty made it worse.

However, the lipedema really kicked into high gear as a young adult and I gained a tremendous amount of weight despite doing everything I could to stop it. Lipedema probably acted synergistically with PCOS and hypothyroidism and that's why the weight gain was so severe.

Dieting seemed to make the lipedema worse. The dieting made me gain weight rather than lose it over the long run, plus it took me close to an eating disorder. For me, it was much healthier to stop actively trying to lose weight. Instead, I follow the Health At Every Size approach and that has been incredibly helpful to me.

The lipedema in my legs and especially my belly got mildly worse with all my pregnancies and I had significant foot/leg edema after two of my pregnancies. However, other than that, it really didn't affect my pregnancies too much. I was fortunate in that way.

The lipedema got worse with peri-menopause and a major car accident but I was still mostly functional. My diagnosis of cancer threw a new wrench into the mix. The treatments for cancer made me develop lipo-lymphedema and I have struggled with that, but Manual Lymph Drainage and compression has helped. My mobility took a big hit; for a while I was in a wheelchair but I can now walk and climb stairs again.

While lipedema and cancer give me significant challenges, I get on with my life and I don't let it derail my happiness. I don't let it silence my voice, my contributions, or my opinions. I will not let the lipedema or the cancer define me.

I try to make sure that I continue to live my life with joy and purpose. Lipedema does interfere with my life, but I refuse to let it make me unhappy or to take away my pleasure in the important things of life. Cancer may take my life eventually but I will live as fully and as joyfully as I can until then.

How has lipedema affected you? And how do you try to handle it proactively?

Thursday, June 2, 2016

Lipedema, Part 8: Living Your Best Life

"Lipoedema does not define us. It's the disease we share."
Image from Lipoedema Australia Support Society
Last year I did a series on lipedema (also spelled lipoedema), sometimes known as "painful fat syndrome" or "big leg syndrome." June is Lipedema Awareness Month so it's time to add to the series.

In lipedema, a fat storage disorder, an abnormal accumulation of fat occurs in the legs and lower body, sometimes including the arms as well. Here is what we have covered so far:
Today, we talk about the emotional and social impact of lipedema, and how important it is to overcome these challenges and live our best possible lives despite lipedema. 

I'd love to hear other women share how they are living their best possible lives despite the challenges of lipedema. And if you have other lipedema-related topics to suggest for future posts, please put them in the comments section.


Emotional and Social Impact of Lipedema 

Lipedema is definitely a challenge both physically and emotionally. It's hard for people without lipedema to understand just how burdensome lipedema can be.

Physical Burden

It's hard to have such a large body and there is definitely a physical burden to it, especially as we age. It takes a lot of energy to move around a very big body, and that can be tiring.

By the time we hit middle age, many of us with lipedema have developed significant joint issues. This is not just from the extra weight itself but also because lipedema predisposes to joint issues. Many people with lipedema have concurrent Ehlers-Danlos Syndrome, Hypermobility Type, a connective tissue disorder that leads to loose ligaments and joint instability. In addition, lipedema predisposes to leakage of fluids into the joints, which irritates them and can predispose to arthritis. Lipedema also causes gait alterations, which in turn causes arthritis and other joint issues.

Beyond just the physical burden of moving around a larger body, lipedema can be quite painful. Even light touches to the legs hurt, sometimes badly. In addition, many with lipedema suffer a deep aching and exhaustion in their legs that is hard to describe to others. In the later stages, some people feel like they've run a marathon, just from standing for a little while or after a short walk. Often there is a significant amount of daily pain and fatigue that must be endured, and anyone who has dealt with chronic pain and fatigue knows how burdensome that can be.

Those who develop severe lipo-lymphedema have a particularly difficult burden. Swelling of the legs, hips, and arms can become extreme. In that situation, it is very difficult to find clothes that fit, and even the simplest mobility can become an issue. Sometimes the swelling (edema) can become so bad that the excess fluid "weeps" out of the legs because the body can no longer dispose of it properly. The lack of efficient lymph circulation predisposes to secondary infections in the legs, and cellulitis and erysipelas infections can become life-threatening if not caught in time or treated adequately.

Bottom line, lipedema is a TREMENDOUS physical burden, and not just from the extra weight. The condition itself, regardless of size, can cause great hardship. 

Emotional Burden

Most people would recognize that lipedema can be a major physical burden in its later stages. What many don't appreciate is how significant an emotional burden lipedema can carry.

It's never easy to have a body that is outside the physical norm. People stare a lot at legs or arms that are so heavy, and it's easy to feel like a freak. Sometimes people can't look away from your legs or arms, or will only look at them instead of talking to your face. Or they sneak quick horrified looks, then determinedly try to focus elsewhere so they don't stare. Even when they try to be polite, their shock, morbid fascination, distaste, and judgment is clear. Because few have heard of lipedema, there's a lot of judgment about your weight and assumptions about your supposed eating habits. 

This can have a real impact on self-esteem. One woman describes it this way:

Coping with my shape, my size, my appearance, all have chipped away at my self confidence over the years, at my self esteem. I hate to see myself in the mirror – I joke with people about my condition, it’s my way of coping, I talk about my ‘tree trunks’ and my built-in ‘sumo suit’, but I don’t find it funny and when I’m on my own I’m not laughing. I don’t like people to see me low, so when I feel low I end up crying on my own. On a bad day I feel that it’s a life sentence I’ve been given.
It's difficult to be larger than average in a looks-obsessed society. Add to that how judgmental friends, family, and doctors believe you about your size and lipedema can be a very difficult thing to deal with emotionally. 

Social and Medical Stigma


People with lipedema face near-universal pressure to lose weight from those around them. They constantly battle their weight, making very little headway against it while constantly being judged by others about what they are eating and whether they are "doing enough." They are often not believed about their intakes, or are expected to strictly adhere to extremely restrictive regimens. This is not a realistic or humane way to live. As another woman shares:
In spite of all the dieting, exercising, massaging and fat-pummelling, the only thing that ever shrunk was my self-esteem, and all I got for my efforts was an eating disorder.
Emotionally and socially, it is very difficult to have lipedema in a disbelieving society. Here is a video that portrays the journey towards diagnosis for many people with lipedema (or as they spell it in Australia, where the film is from, lipoedema).







Unfortunately, no narrative of how hard you've tried to lose weight will ever convince some people that it's not your fault. As a result, there can be a great deal of social stigma for a person with lipedema. Any mobility issues are seen as a logical consequence of "bad habits" and there is little sympathy (and often great mockery) if mobility aids like scooters are needed in the later stages of lipedema. A fat person on a scooter is the ultimate target of disdain for many.

Sadly, in lipedema patients, weight and the mobility issues often combine to create a brutal intersectionality of weight stigma and disability stigma.

Yet many people with lipedema are denied access to treatments that might help them, like lymph-sparing liposuction or knee replacement surgery. Instead, doctors berate us for a condition we cannot help, prescribe the same treatment (weight loss) that has failed over and over, and keep us from the few treatments that might actually help.

Even when we can access these treatments, we often must pay for these things out of our own pockets, because lipedema is not recognized by many insurance companies. This puts them out of reach of many. And because lipedema can be a significant physical challenge in later stages, full-time employment may be difficult, making it even more difficult to afford treatment.

Dealing with Lipedema

There's no question about it, lipedema sucks. Big time.

It's a burdensome disease, physically, emotionally, and socially, yet our burden is added to because few people believe us that lipedema is a real condition. Even when presented with legitimate medical information about lipedema, many call us liars or insist that we are just in denial about our "obesity." 

With so many challenges, it can be easy to get swept up into anger, resentment, and depression over it. As one blogger writes:
Living with lipedema, as with the management of any chronic condition, presents physical, mental, and emotional challenges. 
Physically, my arms and legs are heavy and extremely sensitive, the excess weight causes pressure and pain in my joints and tires me out very easily. 
Mentally, I struggle with the reality of having a progressive condition [for] which little is known, and [for] which few effective treatment options exist and are not readily accessible or require insurance appeals to get covered. 
Emotionally, I live in fear of when my next bought of cellulitis will occur. I am judged and stereotyped based on my appearance. I have been discriminated against in the workplace, and been denied proper medical treatment because of weight bias and stigma. 
I often ask WHY ME?
The question of "why me?" is one that any person with a chronic illness asks. There is no good answer to this. Basically, life is unfair, and that the genetic lottery deals what the genetic lottery deals.

Lipedema is a rotten deal, but it's also true that there are many challenging conditions out there. Sometimes knowing that helps some women deal with the rotten parts of lipedema. 

Yet suffering is not a contest. The fact that someone else, somewhere, is suffering more than we are does not negate our own suffering. All we can do is acknowledge the difficulties that lipedema brings, let ourselves be justifiably angry over the unfairness of it all, but then move on with our lives so that we don't get stuck in anger and defeat.

Life brings everyone challenges; it's how you deal with the challenges that makes the most difference.

Sarah Bramblette is an American woman who has become one of the main ambassadors about living with lipedema. She has appeared on TV and in print talking about her experience with lipedema.You can read a summary of her journey with lipedema and lymphedema here [Trigger warning: mention of bariatric surgery and weight loss as part of her journey].

In another place, Sarah writes about the challenges of living with lipedema, yet not letting it control your happiness. She writes:
While the prospect of having a condition to which I have little control is daunting, I do at least have the knowledge of why I am not able to lose weight normally. Long ago I made the decision to move forward with life, gather up my fight and go full speed ahead. I might not know where I am going, or how my lipedema will progress, but nothing is going to deter me from being me or living my life to the fullest. I had never let my weight hold me back, and I am surely not going to let lipedema, despite the challenges, keep me from living the life I want to live.
Summary


Image from Lipoedema Australia Support Society
Lipedema is a condition in which the fat cells in the body (especially the lower body) are subject to overproduction and overgrowth. In some ways, it's analogous to acromegaly, a condition in which a benign tumor causes the pituitary gland to overproduce growth hormone, which then causes the body's skeletal and soft tissues to overgrow massively. We don't know what causes lipedema, but something causes the body's fat cells to respond abnormally and results in massive adipose tissue overgrowth.

Doctors readily believe that acromegaly is caused by a physical disorder, but sadly, rarely believe that the extra weight from lipedema is caused by a physical disorder. Because they have been trained to believe that obesity results only from sloth and gluttony, they regularly discount that there can be legitimate physical causes for it. Weight bias from society and from medical providers significantly adds to the burden of lipedema.

There is no question that lipedema can be a very challenging condition to live with. It is physically burdensome, but the emotional pain and stigma can be even more burdensome.

Medically, care providers often don't even believe the condition exists. Even when they do, it is challenging to get diagnosis or treatment because an International Classification of Disease (ICD) code for this condition doesn't even exist yet, despite the condition having been discovered 75 years ago. Far too often, women with lipedema are blamed and shamed for their condition and pressured to just lose weight.

There's no two ways about it - lipedema sucks. But like any other chronic illness, lipedema shouldn't be allowed to take away your joy in life.

You can't change the fact that you have lipedema, but you can change how you react to it.

You are the one who maintains control over your life and emotions, and although lipedema is challenging, you can still be happy with lipedema.

You can still have love, you can still have a family, you can still have meaningful work, you can still help others, and you can still find joyful things to do with the time you have on this earth. Many other women with lipedema before you have done so, and you can too.

Lipedema definitely sucks, there's no doubt about it, but we don't have to let it ruin our lives or keep us from happiness. Many women with lipedema live fulfilled and good lives. You can too.

Don't let a diagnosis of lipedema keep you from happiness.


References and Resources

Basic Info About Lipedema

*Trigger Warning: Some of these sites are not fat-friendly or promote dieting behaviors

Tuesday, September 1, 2015

Lipedema Series, Part 6: Finding Clothing That Works

Image from the blog, lipese.com
We have been talking about Lipedema, sometimes known as "painful fat syndrome" or "big leg syndrome."

In this fat storage disorder, an abnormal accumulation of fat occurs in the legs and lower body, sometimes including the arms as well.

In Part One of this series, we discussed the typical features of lipedema and how differentiate between lipedema and lymphedema.

In Part Two of the series, we discussed how lipedema progresses, the different stages of progression, and why it's so important to be aware of lipedema

In Part Three of the series, we discussed the different types of fat distribution patterns, looked at some pictures to illustrate type and stage of lipedema, and detailed how lipedema is diagnosed.

In Part Four of this series, we examined possible causes of lipedema, as well as medical conditions often associated with it.

In Part Five, we discussed possible treatments for lipedema in detail. In order to give more detail about each option, we broke the treatments into several sub-posts:
      Today, in Part Six, we discuss practical ideas on how to cope with lipedema, particularly clothing challenges.

      In the next post, we will deal with the emotional and social impact of lipedema, how our medical care is impacted by weight bias, and how to live proactively with lipedema.

      In the future I will share my own lipedema story and also continue to write about lipedema-related issues.

      Clothing Challenges

      The extra heavy hips and legs of lipedema makes it hard to get clothes that fit. This is very trying for people with lipedema.

      Early in the course of lipedema, the upper body is often a smaller size than the lower body. That makes it hard to find clothing that works. Some women even have to go to multiple stores to fit their body, getting a "straight" size for their upper body and a larger "plus" size for their lower body.

      In the later stages of lipedema, the upper body tends to catch up in size with the lower body, so it may be easier to find things that more or less fits the whole body, or at least to shop from the same store for both top and bottom. However, some lipedema women need "extended" sizes ─ above 3x ─ and it's harder to find stores that. Often you have to order online and just hope the sizes (which vary wildly in consistency) fit.

      Certain types of clothing may be particularly difficult to find for women in the later stages of lipedema. Pants, boots, socks, and outerwear can be a significant challenge.

      Although there are many choices available nowadays on the internet, sometimes you simply cannot find what you need. To get around this, you may have to have some things custom-made for you or learn how to make do without them. Here are some resources that may help avoid that choice.

      Pants

      Finding pants that fit can be a tremendous challenge for women with lipedema because their waist size is usually much smaller than their hip size and because they need pants that work with very large legs.

      In the early stages of lipedema, women can often still buy pants with non-elastic waists. They might gap a little or need some darts to narrow the size, but waistband pants still work. As lipedema advances, however, many women end up wearing elastic-waist pants because the difference in size is so significant. However, this doesn't have to mean "granny" pants; there are a number of decent options available in elastic-waist pants, or you can continue to adapt waistband pants. If you have strong sewing skills, making your own custom pants is another option.

      Many women with lipedema also need to buy wider-leg pants, which can also be a challenge. Still, there are choices; if you google "wide leg pants, plus sizes" you can find a selection available from several companies. One caution, though; some very wide-legged pants like "palazzo" or "harem" styles are not that flattering because they exaggerate leg size. "Boot-cut" pants may be more helpful in finding pants that are wide enough for larger calves and ankles without being cartoonishly large. Pants "for pear shapes" may also helpful if you carry a lot of your weight in your backside and thighs.

      Junonia.com often carries pants for pear shapes or with a boot cut. These are good quality, and some even come in different lengths to accommodate people of different heights. Making It Big, Ulla Popken, and Love Your Peaches also have a selection of "wide leg" pants that might be useful for people with lipedema. There are likely other companies as well.

      Yoga pants (made with both cotton and spandex) may be a more comfortable option than blue jeans for many with lipedema, especially if made in a loose-fitting style. However, this is not the same thing as leggings. Leggings are made to conform closely to legs, so if you are sensitive about people staring at your legs, you might consider loose yoga pants instead of leggings or tight yoga pants.

      Some women with lipedema find they need to wear their pants a bit longer than normal because the legs tend to pull up and get stuck up on the "bracelet" of fat on the calf when sitting. Then when you stand, you have to physically pull or shake the pants leg back down, which draws attention to your cankles. Getting pants with a little longer hemline helps keep the ankles covered even when sitting and avoids the awkward "shake down" maneuver when rising.

      Some women with lipedema skip the pants issue altogether by wearing only maxi-skirts and dresses, sometimes with leggings or compression garments underneath for comfort and compression. You are certainly not obligated to cover your legs with a maxi; wear whatever length of skirt you like! If others don't like it, they don't have to look.

      But the reality is that many women with lipedema are uncomfortable with showing lots of leg, or find that it is difficult to be taken seriously in a professional environment because others focus on leg size instead of on accomplishment. If you want or need a longer skirt length, eshakti.com has some great dress designs that you can customize to your personal preferences and needs (neckline, sleeve length, dress length, etc.) for a little extra money. It's not cheap, but it may well be worth it to get clothing that works for your unique needs. (Watch for their sales if you need to save money.)

      With a little creativity and searching, you can find pants that will work for your lipedemic body, and you also have the option to wear dresses or skirts of a length that make you comfortable.

      Boots

      Boots are probably the most challenging clothing item for people with lipedema. If you live in a temperate part of the world, this is not a big deal; you just don't wear boots. But if you live in an area with a lot of rain, snow, or cold weather, not being able to get boots can be a big deal.

      People in the early stages of lipedema can often still wear boots if they buy wide-calf boots, although they may have to order online to find them. In the later stages of lipedema, though, even the extra-wide boots available on the internet may not work anymore.

      If in doubt, measure around the widest part of your lower leg. That will tell you whether or not you can find boots in your size. One fashion commentator states that boots generally come in 4 different sizes:
      • Standard Calf: 14-15 inches
      • Wide Calf: 16 to 18 ¼” 
      • Extra Wide Calf: 17 ½ to 20” 
      • Super Wide Calf: 18 to 21”
      A very few companies may have boots available to larger sizes. A company called widewidths.com has boots available to calf sizes of 24 inches, for example, but only for very large-sized feet. Their boots run about $300, but can sometimes be on sale for half that price. They state that they have the widest boots available online without ordering custom-made boots, which can run up to $1000 per pair.

      Because it is so hard to find reasonably-priced boots in extremely wide calf sizes, most women with advanced lipedema just don't wear boots. Obviously, this is a challenge in some climates. The lack of boots plus the tendency towards restricted blood flow in the feet may make hypothermia or frostbite a real issue for people with lipedema. That's when you have to start getting creative.

      There are all-weather sneakers that are built for extra warmth in the snow. These provide a bit more warmth on cold days. Companies that specialize in outdoor clothing, like landsend.com, Dick's Sporting Goods, or llbean.com will sometimes carry these. However, they are not always available in the "wide" shoe widths that some people need. Be sure to only buy a shoe that fits well.

      For very cold or snowy weather, some people can make ankle-high lace-up snow boots like these work because the fat starts at the ankle. They do tend to chafe at the bracelet of fat around the ankle, so they aren't really great for hiking or wearing long-term, and they wouldn't work for people with significant lipo-lymphedema, but some women with significant lipedema still are able to use them for short-term.

      For rainy and wet-weather areas, there are options like duck shoes. These are water-proof shoes that only go up to the ankle. Sporting goods stores may carry them. Again, they may not be available in the wider shoe widths needed by many larger people, but it's worth checking into. Dick's Sporting Goods and other similar stores often carry waterproof hiking sneakers as well.

      The sportswear company bigcamo.com carries hunting and fishing gear for big and tall guys. They do have boots and other accessories as part of their website, including "Bog Boots" which come in heights that go up only to the ankle or just above the ankle. These might be an option for people who must be out in the weather as part of their job or leisure activities. You also might be able to take a pair of these to a shoe repair store and inquire about splitting the back and inserting a gusset or lace-up area to add more room if these are close to fitting.

      Liposuction is an appealing option for some women with lipedema just so they can have access to having boots (and dry, warm feet) again. Here is the story of one woman who was able to fit into rain boots again after having liposuction.

      Socks, Nylons, and Tights

      Socks are tough because you need them for most shoes. Yet socks in the traditional heights (knee height or 3/4 socks) do not work well on lipedemic legs because they usually roll down or sag.

      In the early stages, knee or trouser socks made for larger calves can work, but may restrict circulation at the elastic top. This could be a disaster for someone with lipedema. By the latter stages of lipedema it is usually not possible to find knee-height socks that fit anymore. 3/4 socks (partway up the calf) can work for those lipedema types whose fat stops around the knee or just below it. Many people with full-leg lipedema just buy ankle socks (1/4 socks) or footie socks.

      Good wool socks can help keep cold lipedema feet warm, yet are more breathable than cotton or polyester blends. Experienced outdoorsy types know that if cotton socks get wet, they quickly lead to hypothermia; wool socks keep you warm even if they get wet. BUY WOOL if you are going to be in outdoor weather for long!

      Smartwool is a very good brand, but Darn Tough socks are even better. They even have a replace-it-for-free guarantee; I can't say enough good things about the Darn Tough wool socks.

      Both Smartwool and Darn Tough have wool socks available in various thicknesses, including padded socks for hiking, extra warm for winter, or ultra lightweight for summer. Although most people would not think of wool socks in summer, I actually find them more comfortable and cooler than cotton or acrylic socks. Smartwool and Darn Tough are more expensive than regular socks, but they are worth the expense. They can be bought via Amazon, REI, or other sportsgoods stores.

      Tights and nylons work under dresses for many lipedema women. However, in order to get them to fit the hips and thighs, you may need to get them in a larger size, even if you don't weigh as much as the charts listed for that size. Many plus-sizes stores like Lane Bryant and Catherines have tights and nylons available to very large sizes. Long underwear in men's sizes is another option for adding warmth and coverage to legs underneath a dress or skirt in cold weather.

      Of course, the best choice for leg coverings may be custom-made compression garments, which can provide warmth as well as compression for those who need it. A company called Lipedema Products has some of the best options for these because they are made in lighter degrees of compression specifically for women with lipedema, rather than the higher compression used for lymphedema.

      Coats and Outerwear

      Coats and outerwear can be difficult for people with lipedema. Many people with lipedema live in very cold or wet areas and want to stay active, but the sportswear gear in large sizes is extremely limited and can be quite inferior in quality. A larger size is often needed in order to fit large arms and hips.

      Although many plus-sized coats are now available online and in some stores, many of them are of lackluster quality. Many aren't that warm, don't "breathe" well, use inferior fabrics, and aren't waterproof or windproof. Frankly, it's still pretty difficult to find a truly good-quality coat that fits lipedemic shapes, and finding rain pants or snow pants that fit lipedemic legs is a nightmare. Look around carefully before making your choice.

      Even when quality gear can be found, it is often very expensive. Still, you never know what can be found at Goodwill or on eBay, so it's always worth checking secondhand sources if you need to save money.

      Junonia.com often carries coats and outerwear in plus sizes, as well as women's clothes. The quality varies greatly; I've gotten great stuff there, and I've gotten some very inferior stuff as well. You never quite know what you're going to get; don't be hesitant to send back inferior stuff. The good news is that it typically is cut well for women's bodies, with extra room in the seat and legs. Junonia is one of the few companies that has catered to sportswear and outerwear made to fit plus-sized women's bodies.

      Landsend.com and llbean.com also have excellent-quality coats and outerwear in plus sizes for women. However, their sizes usually only go up to 3x and tend to run small. So while some lipedemic women can shop at these companies, others will not find their sizes in the women's department.

      When you can't find your size in women's plus sizes, the secret to finding decent outerwear may be in men's "big and tall" sizes. Women of size shouldn't have to shop in men's departments in order to find clothes that fit, but the reality is that sometimes the only way to get larger sizes is to go to the men's department. Although men's plus sizes are cut for bigger bellies and skinnier legs, some styles will work for lipedemic women, so check the above companies' men's sections too.

      Columbia.com is an online company that makes good-quality outerwear for active people. Their women's sizes are limited, but their men's extended sizes often have selections available to 4x and occasionally larger. These are usually of excellent quality, but of course tend to be sized tall. You may have to have them shortened if you are vertically challenged like me.

      Bigcamo.com is an online company that specializes in hunting, fishing, and outdoor gear for larger men. They carry 4x - 8x gear from a variety of companies, and sometimes are able to hire a company to make a small run of larger-sized gear in things like rain suits. This could be another resource for some lipedemic women.

      It is a tremendous disappointment that better-quality gear is not available in women's plus sizes. Apparently, clothing manufacturers think that fat women sit inside on the couch all day and never venture outside. But women of size DO live in cold and wet climates, many DO like to go hiking, garden, and stay active, and even those who don't still have to go outside for daily life, like going to a child's soccer game in a rainstorm. Manufacturers make quality outerwear for men's extended sizes; it's about time they branched out into quality outerwear for women's extended sizes too. Otherwise, they are missing out on a major market opportunity.

      Adaptive Garments 

      For those with lipedema who develop significant lipo-lymphedema as a late complication of the condition, clothing, outerwear, and shoe choices can be even MORE difficult, especially if mobility is impaired and a walker or wheelchair is needed at times.

      There are many companies that specialize in garments for people with mobility challenges, including those with lymphedema. You can find a list of some of these companies here. Another option is to have some clothes custom-made for your needs.

      Conclusion

      There's no doubt about it, having lipedema can make finding decent clothing a real challenge. Pants, boots, socks/tights/nylons, and outerwear are particularly difficult to find.

      This lack of access to decent clothing really hits at a woman's sense of self-esteem. It's hard enough to feel positive about one's body with lipedema; it's even worse when one can't find good-fitting or flattering clothing. It's a double blow to the ego, and sometimes it drives people to avoid others or limit their opportunities.

      However, women have been dealing with lipedema for eons. Most find ways to cope, whether that's adapting clothing they already have or having something custom-made. And really, we have a LOT more choices now in the age of the internet than we ever did back in the days of a tiny plus-size department in the neighborhood big-box store.

      The key is to GET CREATIVE. If that means searching far and wide online to find suitable clothes, shopping in the men's department, having special clothes custom-made, sewing our own clothes, or pressuring the clothing industry to better address our needs, so be it.

      Finding suitable clothing with lipedema is challenging, but we can do it. And through advocacy and raising awareness of lipedema, we can keep improving our choices over time.

      Remember, ROCK YOUR CURVES. Even with challenges, it's all about self-confidence. If you don't have confidence, fake it till you make it ─ they'll never know. It's all about the way you present yourself to the world. The difficulties of lipedema are real, but they don't have to keep you from reaching your full potential.


      *I'm sure there are many other great companies besides the ones listed above that offer clothes that might work for lipedemic women. Do you have other suggestions that have worked for you? Please add your ideas in the comments.