Why are lipedema and obesity often confused?
Lipedema and obesity may look similar to each other from the outside. Both go with an increase in volume in the body. Especially if there is significant enlargement in the hip, head, thigh and calf area, the patient often thinks "I have gained weight" at first. Comments from the environment are often in the same direction: eat less, walk more, lose weight.
This is where it gets tricky in the clinic. Obesity is a metabolic condition characterized by a general increase in adipose tissue in the body. Lipedema, on the other hand, is a different distribution of adipose tissue, especially in the legs, sometimes in the arms, and can be accompanied by pain and tenderness. These two tables are not the same thing. But it can also be found together in the same patient.
What is lipedema, which is the main guide to the general definition, symptoms and stages of lipedema? Symptoms, stages and diagnostic guide
explains the basis of this issue. In this article, we will focus on a narrower but very important question: "Is this condition lipoedema or obesity?"
"I'm losing weight, but my legs aren't getting thinner, is that normal?"
We often hear this sentence from patients with lipedema. The patient diets, loses weight from the upper body, the waist circumference decreases, the face becomes thinner. However, the hip, thigh, knee circumference or calf area does not change at the same speed. Sometimes the scale falls off, but the trouser size remains almost the same.
This condition alone does not diagnose lipedema. Nevertheless, it is a remarkable clue in terms of lipedema. Because lipoedematous adipose tissue may be more resistant to classical weight loss. As the patient loses weight, the trunk and abdominal circumference become thinner, but the lower body may not give the expected response.
It is not right to blame the patient here. The sentence "You are not trying hard enough" is a sentence that these patients have heard for years but often does not explain the problem. The more accurate approach is to look together at fat distribution, pain, tenderness, tendency to bruise, condition of the feet and regional response to weight loss.
What is obesity, how is it different from lipedema?
Obesity is the increase in adipose tissue in the body at a level that can affect health. Most often, the circumference of the abdomen, trunk, back, arms and legs are affected together. Insulin resistance can be seen together with conditions such as hypertension, fatty liver, sleep apnea and cardiovascular diseases.
In lipedema, the increase in adipose tissue is mostly concentrated in certain areas. Hips, hips, thighs, knee circumference and calf line are more noticeably affected. In some patients, the arms are also involved. There may be a noticeable disproportion between the upper body and the lower body.
Another difference is pain. In obesity, adipose tissue is usually not painful to touch. In lipedema, tenderness to touch, pain like bruise, discomfort with pressure and easy bruising can be seen in the legs (Forner-Cordero et al., 2012 [3]; Herbst et al., 2021 [4]).
So it's not just about weight. It matters where fat collects in the body, how it feels, and how it responds to weight loss.
How is fat distribution different in lipedema?
In lipedema, adipose tissue is mostly symmetrically distributed. So the two legs are affected in a similar way. There may be a significant increase in volume in the hips, hips, thighs, knee circumference and calf line. In the classic table, the feet are usually preserved. Therefore, a transition like a "cuff" can occur at the ankle level.
In obesity, fat gain may be more general. The abdomen and waist circumference may become prominent. The torso and upper body are also affected by weight gain. In lipedema, the patient sometimes describes a thinner appearance in the upper body and a wider appearance in the lower body.
This distinction is also evident in daily life. The patient can use smaller size clothes in the upper body and larger size clothes in the lower body. It becomes difficult to find trousers. Boots, skinny trousers or clothes that fit around the knees can be uncomfortable.
Previously published types of lipedema
explains these regional involvements in more detail.
Why are pain and tenderness important in differentiation?
Pain is one of the distinguishing features of lipedema. In areas with lipedema, there may be pain to touch, tenderness with pressure, pain like bruises, or a feeling of heaviness at the end of the day. Some patients say, "My legs are always bruised". Some describe extreme sensitivity during massage.
Obesity may also cause joint pain, low back pain or difficulty with movement. But this pain is often associated with mechanical load. Touch sensitivity in lipedema is different. The subcutaneous tissue of the leg feels more painful.
The 2024 S2k lipedema guide highlights pain and pressure sensitivity more prominently in the definition of lipedema. Painless disproportionate increase in adipose tissue can be considered as lipohypertrophy rather than lipedema. Lipohypertrophy is the disproportionate increase in adipose tissue seen without pain (Faerber et al., 2024 [2]).
This distinction changes the treatment plan. In a painful and sensitive lipedema tissue, exercise, compression and manual lymph drainage should be planned more carefully.
What does it mean to protect the feet?
In classic lipedema, the feet are often not noticeably affected. There is an increase in volume in the legs, but the back of the feet and fingers may look more normal. A sharp transition in the ankle is remarkable in terms of lipedema.
In obesity, the feet can also be affected depending on body weight. In lymphedema, the back of the foot and fingers are more frequently involved. Therefore, the condition of the feet is especially evaluated during the examination.
Preservation of the feet may be a finding in favor of lipedema, but it does not make a diagnosis on its own. Because a patient with lipedema may also have venous insufficiency, lymphedema or obesity-related edema. If there is significant swelling on the back of the foot, fullness in the fingers or permanent edema, it is necessary to consider non-lipoedema causes.
Can easy bruising be a finding in favor of lipedema?
Yes, easy bruising is one of the common findings in lipedema. The patient may bruise with small blows or sometimes does not remember what he hit. Bruises can be noticed especially around the thighs, knees and calf area.
Easy bruising in obesity is not a typical main finding. Of course, not every bruising means lipedema. Blood thinners, clotting disorders, liver diseases, certain vitamin deficiencies or hematological diseases can also cause bruising.
For this reason, if bruising is very common, has just started, is accompanied by bleeding from the nose or gums, or if it is thought to be related to the drugs used, a physician's evaluation is required.
To read the symptoms of lipedema in more detail, see Symptoms of lipedema
will be complementary.
Why can the response to diet and exercise be different?
When weight loss is achieved in obesity, adipose tissue may decrease in many parts of the body. This response varies from person to person, but in general, thinning can be seen in the abdomen, trunk, face, arms and legs.
The situation may be different in lipedema. When the patient loses weight, the upper body becomes thinner, but the areas with lipedema may remain more resistant. This does not mean that diet and exercise are unnecessary. On the contrary, nutrition and exercise support metabolic health, insulin resistance, edema sensation and movement capacity in patients with lipedema.
However, the expectation should be realistic. It is often incomplete to say "just lose weight, everything will be fine" to the patient with lipedema. More accurate goals are: reducing pain, controlling the sensation of edema, supporting the muscle pump, preventing weight gain, reducing metabolic load and improving quality of life.
In the clinic, sometimes measurements rather than scales guide the way. Waist, hip, thigh, knee circumference and calf measurements should be followed regularly. The same time, the same conditions, and the same measurement points must be used.
Can lipedema and obesity be together in the same person?
Yes, it can. This is a very important point. A patient with lipedema may also have obesity. A patient with obesity may also develop lipedema. The two situations are not mutually exclusive.
When they are together, the picture becomes more complicated. Excess weight can strain the lymphatic system, affect venous circulation, reduce movement capacity, and increase pain. Areas with lipedema may not give the expected response to weight loss. The patient may experience a loss of motivation because of this.
The treatment plan should be prepared by seeing this distinction. If there is obesity, weight management should not be neglected. If there is lipedema, the patient should not be given only a weighing target. It is necessary to manage both at the same time.
Pouwels et al. (2023 [7]) highlight that obesity, venous disease, lymphatic disease, and lipedema can be confused and co-present in the same patient. In practice, the equivalent of this is this: The examination should not be done only on the basis of "weight".
Why is BMI alone not enough?
BMI, or body mass index, is the evaluation of weight according to height. It is a practical measure at the level of society. However, it is not sufficient alone for the diagnosis of lipedema.
A patient with a high BMI may have obesity. But this does not mean that there is no lipedema. A patient with a normal BMI may also have lipedema. Especially if the upper body is thinner and the lower body is significantly wider, BMI may not fully describe the picture.
Therefore, in the suspicion of lipedema, BMI, body proportions, waist circumference, hip circumference, thigh and calf measurements, pain, bruising, condition of the feet and regional response to weight loss are evaluated together.
In some patients, the waist/hip ratio may also give an idea. But it does not make a diagnosis on its own. Lipedema is a clinical evaluation; In other words, the patient's history and examination findings are read together.
"I was told to just lose weight, but it hasn't changed for years"
This sentence is one of the most tiring experiences of the patient with lipedema. Many patients diet for years, lose weight, gain it again, go to the gym, try different lists. Despite this, he cannot see the change he expects in his legs.
Two mistakes can be made here. The first is to tell the patient that "you are lipedema, weight is not important". This is not true. Metabolic health, weight management and diet are important.
The second is just telling the patient to "lose weight". This is also incomplete. Because lipoedematous adipose tissue may be more resistant to classical weight loss. Pain, tenderness, edema and limitation of movement should be addressed separately.
The right approach is to proceed without blaming the patient, but without completely eliminating responsibility. Nutrition, exercise, manual lymph drainage, compression, sleep, stress management and, if necessary, surgical options should be considered together.
What is checked in a doctor's examination?
In the examination, the fat distribution is first checked. Is the volume increase in the torso, lower body, arms, unilateral or symmetrical? Hips, thighs, knee circumference and calf line are also evaluated.
Then the condition of the feet is examined. Are the back of the feet and fingers involved in the swelling? Is there a cuff appearance on the ankle? Stemmer's finding can be evaluated. Stemmer's finding is the inability to hold and lift the skin at the root of the second toe of the foot and may be in favor of lymphedema.
Pain and tenderness are also questioned. Pain to touch, easy bruising, feeling of heaviness at the end of the day, increase in hot weather, relationship with the menstrual period and change when standing for a long time are asked.
The vascular system should also be reviewed. Venous evaluation is required if there is varicose veins, increased swelling in the evening, discoloration of the leg, itching, history of venous ulcers or unilateral sudden swelling.
Examinations such as venous doppler ultrasound can be performed when necessary. However, there is no single blood test or single imaging method that diagnoses lipedema. Diagnosis is often made by a well-taken history and careful physical examination (Peled and Kappos, 2016 [6]; Herbst et al., 2021 [4]).
In which cases should other diseases be considered?
Lipedema is usually a slow course. Sudden onset symptoms should not be interpreted as lipedema.
Urgent evaluation is required if there is unilateral sudden leg swelling, redness and temperature increase in the leg, new-onset severe pain, significant tenderness in the calf, shortness of breath, chest pain, fainting or fever. These may be associated with vascular occlusion, infection, or other serious conditions.
Some more slowly developing findings are also important for differential diagnosis. Lymphedema and venous insufficiency should be investigated separately if there is swelling on the back of the foot and fingers, edema that leaves a pit in the leg due to pressure, varicose veins, itching, brown discoloration of the skin, frequent infections or wound dehiscence.
The diagnosis of lipedema is not to ignore other diseases. A good evaluation should also see obesity, venous insufficiency, lymphedema and metabolic problems that may coexist with lipedema.
How does the treatment approach change?
If obesity is at the forefront, calorie balance, diet, physical activity, sleep, insulin resistance, fatty liver and cardiometabolic risks are more prominent in treatment. Here, the goal is not just aesthetics; blood sugar, blood pressure, liver, joint health and cardiovascular risk are also evaluated.
If lipedema is at the forefront, the treatment takes a different framework. Nutrition is still important, but pain, tenderness, edema, lymphatic load, compression, manual lymph drainage, low-impact exercise and psychological load are also added to the plan.
If the two tables are together, the plan should be more personal. Weight management is not neglected. The regional resistance of the lipoedematous tissue is also clearly explained to the patient. Thus, the patient knows what can change, what will change more slowly and what indicators need to be followed.
In practice, the healthiest follow-up is as follows: scale, circumference measurements, pain level, feeling of heaviness at the end of the day, clothing fit, movement capacity and examination findings are evaluated together. Making decisions based on a single number is often misleading.
Frequently asked questions
Question: Are lipedema and obesity the same thing?
Answer: No. Obesity progresses with an increase in general adipose tissue in the body. Lipedema, on the other hand, is a different picture that can manifest itself with pain, tenderness, easy bruising and disproportionate fat distribution, especially in the legs and sometimes in the arms.
Q: Can someone with lipedema lose weight?
Answer: Yes, a person with lipedema can lose weight. However, areas with lipedema may be more resistant to weight loss. It may be remarkable in terms of lipedema that the legs do not change at the same speed while the upper body is thinning.
Question: Can lipedema not be diagnosed if there is obesity?
Answer: No. Obesity and lipedema can occur together in the same person. In this case, both metabolic weight management and the pain, tenderness, edema sensation and regional resistance characteristics of lipedema should be considered together.
Question: Is BMI sufficient for the diagnosis of lipedema?
BMI is calculated based solely on weight and height. Findings such as fat distribution, pain, bruising, protection of the feet, symmetry and regional response to weight loss in lipedema should be evaluated separately.
Question: Is it important for the feet to look normal in lipedema?
Answer: Yes. In classic lipedema, the feet are preserved most of the time and a cuff-like transition can be seen in the ankle. If there is significant swelling on the back of the foot and fingers, lymphedema or other causes of edema should also be considered.
Question: Is leg thickness resistant to every diet lipedema?
Regional fat, genetic body structure, obesity, venous insufficiency, lymphedema and hormonal conditions can also affect the appearance of the legs. The diagnosis of lipedema is made with pain, tenderness, bruising, symmetry, condition of the feet and examination findings.