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Z. Jandali et al.
In addition, there are symptoms such as mood swings, loss of drive and motivation, sleep disturbances, and the classic complaints of the musculoskeletal system.
The preceding symptoms also support further weight gain.
There is a change in body fat distribution from the premenopausal gynoid pattern
(pear type) to the postmenopausal android pattern (apple type).
Fat Distribution
Apple type and Pear type? That is only guratively speaking! If we look at the
gender-specic characteristics of fat distribution, we often see in men bellyemphasized fat tissue storage with fat deposits around the internal organs, but also
in the subcutaneous fat tissue on the abdomen. Here we speak of the central type,
the “apple type.” The situation is different in women, in whom the adipose tissue is
already located to a greater extent in the buttock–hip area for genetic reasons. This
distribution is referred to as the “pear type” (Fig.1.22).
The transition from pre- to postmenopausal is often also the time when lipohypertrophy rst develops, painfully changes to lipedema, or when preexisting
lipedema worsens. Lipedema adipose tissue, often referred to as “lip fat,” is often
initially found in the bulbous regions of obese individuals. We try to avoid the term
Fig. 1.22 Apple and pear type
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“lipid fat“because it suggests that one can distinguish adipose tissue of lipedema
from healthy adipose tissue with the naked eye or via ultrasound, when in fact only
some immunohistochemical markers are able to do so. In only slightly overweight
and slender women, however, we often nd the fat distribution disorder in the area
of the entire lower extremity, often as a so-called columnar leg, where the entire leg
contour resembles a column (Fig.1.23).
The male apple type is much more harmful than the female pear type.
Especially dangerous is the abdominal fat, that is, the fat around the organs.
Fatication of the abdomen—and this has been scientically proven—has a detrimental effect specically on the function of the internal organs. For women, an
abdominal girth of 80cm or more and for men, 94 cm or more is considered
harmful (Fig.1.24).
Waist circumference is associated with the amount of “belly fat” and is
c
closely related to cardiovascular disease.
Calorie Turnover
As already mentioned in Sects. 1.2.3 and 1.2.6, we often do not use as much energy
as we consume. The surplus is simply not utilized but is stored in the adipose tissue.
Moreover, if one suffers from an estrogen receptor distribution disorder, as is suspected in lipedema, even less energy is probably sufcient to store fat.
In the past, storing fat was necessary for survival, because we didn’t know when
we’d next have something to eat. We built up a bacon coat for the winter as heat
insulation and energy storage. Nowadays, this is different. Our food supply is
Fig. 1.23 Examples of different column legs
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Fig. 1.24 Circumference
measurement at the waist
Z. Jandali et al.
secure. Nevertheless, our body still thinks and works according to the old principles.
Eat whenever possible! For us humans, the development into prosperity simply happened too fast for our behavior to have been able to adapt through evolution. Our
eating behavior, thus, lags far behind the current supply. We must therefore actively
take countermeasures to change our behavior.
Our daily total caloric expenditure is on average 2300kcal and consists of a
basal metabolic rate and activity metabolic rate. The basal metabolic rate can be
roughly estimated. Multiply the body weight by 24 and you have a very good
approximation.
The caloric basal metabolic rate can be roughly estimated using the
c
formula: Bodyweight × 24.
But if you want to know more about it here in detail:
The basal metabolic rate is the amount of energy required by the body at rest and
at indifference temperature (28°C) during 1 day (24h) to maintain its function. It
is, so to speak, the “standby turnover.” Of course, many factors play a determining
role in the basal metabolic rate, for example,
– Age.
– Gender.
– Bodyweight.
– Body size.
– Proportion of muscle mass.
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– Ambient temperature and thermal insulation by clothing as well as.
– General state of health.
To calculate the basal metabolic rate, the “Harris–Benedict formula“has proven
itself. The value is not exact, but a very good approximation to the real basal metabolic rate. In the basal metabolic rate, the brain, heart, and kidneys have the highest
demand for energy.
For women:
39
Basal metabolic rate,body weight/( ,
118 47, body height ,
Although not many men will read it, here the formula for comparison:
Basal metabolic rate
If we now go into further detail, we can name the energy metabolism of various
tissue components (Table1.3). Although the brain accounts for only about 2% of
body weight, it consumes quite a lot of our daily basal metabolic rate. We can
roughly say that 20% of the basal metabolic rate is consumed by the brain. 500g of
brain mass consumes about 110kcal per day. Our brain has an approximate weight
of 1500g, which makes a brain calorie basal metabolic rate of 330kcal per day. The
special thing about the brain is that it can only burn sugar and takes it directly
from food.
Kidney tissue consumes about 200kcal per day. One kidney weighs about 130g.
500g of muscle mass consume 6kcal, 500g of fat 2kcal per day.
Our brain burns an average of 330kcal per day and can only utilize sugar.
c
Power Conversion
Our activity or power metabolism is the amount of energy that we burn in 1day with
our body. This turnover is mainly generated by brain and muscle activity (work,
leisure, sport). To calculate the conduction metabolic rate, we use the PAL value
(“Physical Activity Level”; Table1.4; Fig.1.25).
568body height cm ,age years
kcal
655 196
hkg24
cm age years
cal
k
66 47 13 7
h24
, body weight kg/( ,
Table 1.3 Energy metabolism by tissue
Tissue
Brain 1500 330
Kidney tissue 130 200
Muscle tissue 500 6
Fat 500 2
Mass (g)
Consumption per day [kcal]
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Table 1.4 PAL value
Factor
0,95 Sleeping Night rest
1,2–1,3 Sitting, lying Seniors, bedridden people
1,4–1,5 Sitting, little physical activity Desk workers
1,6–1,7 Predominantly sitting, walking,
1,8–1,9 Predominantly walking and standing Salespersons, waiters, mail carriers
2,0–2,4 Physical work Construction workers, farmers, loggers,
Activity
standing
Example
Pupils, students, bus drivers
athletes
Fig. 1.25 PAL values
For this purpose, the factors are multiplied by the respective number of hours and
then added. To obtain a daily average, this number must be divided by 24. To determine the total energy requirement, the daily average is multiplied by the basal metabolic rate. The result is the average total energy requirement (Fig.1.26). The daily
total calorie requirement thus varies from individual to individual.
Let us now take a look at the calories’ consumption of other activities: We assume
a person weighing 70kg and the calories consumption within 1h (Table1.5).
Energy Intake and Eating Behavior
Let’s look now at energy intake and how we supply ourselves with energy. The
“how” may sound strange at rst, but our eating habits are more unfavorable than
ever before. We are talking here about our eating behavior. We eat on the side, standing up, and often stressed—all negative characteristics.
Many eat only in between and unconsciously, for which they should not be
blamed. In a big city, the most appetizing treats are held under our noses virtually
every 50m. Not only in the pedestrian zones but also on the roadways we nd inviting fast-food snacks against ravenous appetite. It’s often difcult to resist as we
walk by, and if we don’t nd anything as we pass by, we subconsciously know that
an online ordering food center won’t let us down. This gives us added condence
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Fig. 1.26 Calorie requirements by activity level
Table 1.5 Calorie consumption within 1h
Activity Kcal/h
Weightlifting 224
Water gymnastics 149
Cycling (moderate) 260
Rowing (moderate) 260
Cross trainer 335
Billiards 93
Golf 130
Walking (6,4km/h) 167
Jogging (12km/h) 465
Gardening 167
Sleeping 23
Cooking 93
TV 28
In standing in a queue 47
Playing with the kids 147
Wallpapering/painting 167
Computer work 51
Counter work 65
Forestry worker 298
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Z. Jandali et al.
that we won’t go hungry. Conveniently, we kill two birds with one stone with delivery services: rst, we get the food delivered and don’t have to “pick or hunt” like we
used to, because that also used to burn a very large percentage of calories. Second,
we don’t even have to go to the trouble of preparing it! What a luxury we live in.
What we don’t know is what’s really in the products. Besides avor enhancers, there
are huge amounts of fats and sugars in the products. Therefore, our food is often
unbalanced and one-sided. Vegetables, fruits, and other things are completely missing in many such items. Ready-made meals are often no better (Fig.1.27).
We haven’t even discussed two major calorie bombs yet: sweets and soft drinks.
In Germany, around 31kg of sweets are bought and eaten per capita every year, and
Fig. 1.27 Healthy and unhealthy food
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on average, every German drinks around 133 liters of soft drinks, the liquid sugar
bombs, per year. In the USA, on the other hand, 195l are drunk per person. A truly
frighteningly high gure.
Expectations of one’s own role and social stress are further factors. Eating disorders of various kinds are often present. Obesity due to a psychological cause (socalled psychogenic obesity) is not in itself a distinct clinical picture, although a very
high number of people suffer from this cause of obesity.
However, many of those affected are not even aware of the psychological background of their suffering. Most often, binge eating is used to regulate emotions.
Often, people with psychogenic obesity use food to cope with unpleasant or disturbing feelings such as loneliness, stress, anger, boredom, overwhelm, sadness, disregard, or trauma (whether violent or sexual). Sometimes weight gain is said to
unconsciously cause one to acquire a “protective armor” and thus lose
attractiveness.
In many cases, those affected are internally oversensitive and vulnerable. Eating
is used as a way of regulating feelings. Many speak of so-called substitute satisfaction in these situations.
In addition, there are negative habits: Some eat when they are stressed, others
when they are successful, and others eat throughout—whether at work or on the
road—a little candy here and a piece of cake there.
Did you know that with age the body learns to digest food better? Therefore, the
nutrient yield in old age is better than in youth. Another reason why we get by with
less food as we age.
Finally, we have the suffering topic of smoking. Many people try to quit smoking, especially nowadays when smoking is becoming more and more frowned upon
and unpopular. The undesirable side effect is an increase in body weight. The exact
reasons why we gain weight when we stop smoking are many. In addition to an
abolished appetite control, the “substitute drug candy” is often to blame.
Energy Consumption and Lifestyle
As with energy supply, we are also dealing with a multilayered issue when it comes
to energy consumption. Our own lifestyle plays a major role. This is often inactive
and passive. Even short distances are covered by a car. Hunting and gathering are
long gone. We live in a society of comfort, in which we allow ourselves to be
entertained.
Psychosocial factors also play a role here. The inuence of an intact family
(nuclear family) and intact family life, as well as friends and circle of friends, are
important for our activity.
Do you walk the stairs or take the elevator? Even up to the fth oor? What about
sports? Do you go to the gym or have you only been paying your contributions
for years?
Our very own biology doesn’t help us to keep our weight either because in principle we only have two programs inside us. One program tells us to eat whenever we
nd something to eat (we just discussed that). The second program tells us to conserve as much energy as possible, that is, to move minimally to stay at maximum
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strength. That’s why we feel so comfortable “chilling.” In the past, at least, we
burned energy hunting and gathering. Today we reach for the tablet or cell phone.
We prefer cars and other means of transportation and are happy to leave the bike
behind. For the most part, walking no longer nds a place in our fast-paced times.
Our workplaces often involve a lot of sitting, and you can already tell we’re “chilling through life.” One could cite many more examples here that would underline our
“chill mentality.”
In addition, there is the psyche, which we will discuss in detail in the following
section. The background is that lipedema sufferers, who suffer from chronic pain,
exclusion, and strong dissatisfaction with their appearance, are often plagued by
depressive mood or actual depression.
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1.7 Complaints andEffects ofLipedema
We have already talked about pathomechanism, which is still unknown to us, and
obesity, which often occurs in combination. Now it is time to talk about the symptoms and the course of the disease “lipedema.” Since lipedema can be a chameleon,
there are statements we can make in general, but likewise, there are always
exceptions.
Typically, lipohypertrophy starts in the area of the lower extremities (incl.
Buttocks and hips). Accordingly, it is often seen at the rst moment merely visually:
“Something is wrong here.” Subsequently, those affected notice a feeling of heaviness in the legs and only then, in the further course of the disease and the later
stages, there is a feeling of tension and pain in the area of the affected regions.
Most often we see that lipedema starts in the lower half of the body and then
moves to the upper part of the body.
Typically, lipedema begins after the onset of lipohypertrophy in the
c
lower extremity. Only in the later stages can the upper extremity be
affected.
We see a wide range of sensitivity to touch and touch pain in our patients. For
many, it is even the smallest touches and strokes that can trigger an unpleasant feeling or even pain. This often leads to a withdrawal from the own relationship with the
resulting further conict-building sites.
From our clinical experience, further typical complaints are feeling tension or
pain in the sense of pressure pain, touch pain, or tearing pain. Mostly the complaints
occur during the day and bring restlessness in the legs. In many cases, the pain is
most pronounced in the evening. If there is temporary or permanent edema, then a
worsening of the symptoms with an increase in edema during the day is often
reported.
The curious thing about our current system is that if you suffer from a fat distribution disorder, you are only recognized as “sick” if you have pain. If one has no
pain, one is considered healthy. In fact, one is treated only when one reaches a
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certain visual stage, but this has nothing to do with pain. If one does not see anything visually or if one can only rudimentarily recognize a fat distribution disorder
and the patient states severe pain, she is still considered healthy (or a spinner, which
is even worse). But even if both criteria apply, that is, a fat distribution disorder is
associated with pain and the patient is overweight, she will not have an easy time
with treatment.
We see very many affected persons—whether normal or overweight—who do
not suffer from pain but a restriction of their mobility. Regardless of the visual
stage, in our view, a restriction of movement is pathological above a certain level
(Fig.1.28).
It is often deforming fat pads on the inner thighs and knees (Fig.1.29) that cause
restricted movement. In addition to a leg malposition, these lead to increased
Fig. 1.28 Movement
restriction due to excess
skin and adipose tissue
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