Purpose: Lipedema is a common and painful fat disorder affecting the limbs of women leading to obesity; the fat cannot be lost by diet or exercise, called persistent fat . Lipedema is classified by stage. Stage 1: normal skin surface with enlarged hypodermis. Stage 2: uneven skin with indentations in fat and larger hypodermal masses. Stage 3: large extrusions of tissue drastically inhibit mobility. Lymphedema occurs at any stage, especially Stage 3, called lipo-lymphedema. Reduction of lipedema fat is achieved effectively only by removal of fat by lymph-sparing liposuction. Liposuction reduction of fat on the lower body improves mobility. Data from Europe demonstrate quality of life improves for women with lipedema after liposuction. There are no data on liposuction and lipedema in the United States (US). The purpose of this study is to determine how women with lipedema in the United States benefit or not from liposuction. Materials and Methods: Non-validated 183-item online questionnaire answered by women after undergoing liposuction for lipedema in the US. Results: One-hundred and eighty-nine women with lipedema consented and answered the questionnaire; the majority (51%) Stage 2. Women with Stage 1 and 2 had on average two procedures; women with Stage 3 or lipo-lymphedema had, on average, one additional procedure. Improvement in ambulation after liposuction was highest in patients with lipedema Stage 3 at 90.9% and lowest in Stage 1 at 71%, where ambulation pre-surgery tends to be less affected. Weight loss occurred in all groups 2-4 months after liposuction. Women from all stages reported growth of fat post-procedure outside areas of liposuction, highest in Stage 1 (62%) and lipo-lymphedema (70%). Growth of fat in liposuction areas occurred in ~1/2 of participants across all groups, most often in women in lipedema Stage 4 (71%). The complication of lymphedema after liposuction was not reported in Stage 1 but in two women with Stage 2, five with Stage 3, and three with lipo-lipedema. Improved quality of life after liposuction was significant in Stages 1-3 ranging from 81% improvement for Stage 1 to 86% for Stage 3, but only 70% for women with lipo-lymphedema. The perceived success of the procedure decreased with stage. Conclusion: Women with lipedema noticed improved ambulation after liposuction, likely due to removal of excess adipose tissue from the legs. Fat growth after liposuction was reported consistent with published data. Improvement in quality of life after liposuction agrees with European data, and greater perceived benefit in earlier stages emphasizes the importance of early detection of lipedema and earlier intervention with liposuction. Prospective studies are needed to assess quality of life, fat growth, weight loss and ambulation after liposuction in women with lipedema in the US.
Background: Diabetes (DM) and obesity are related health issues which are increasing in prevalence. But not all obesity is related to DM. Women suffering from Lipedema are categorized as gynoid obese. Nattokinase (Natto) is an enzyme supplement that has been shown to degrade fibrin. Patients with obesity tend to have elevated clotting factors which can lead to adipose tissue hypoxia, impaired insulin signaling, and lead to insulin resistance. Research in fat disorders noted that fat biopsies from women with Lipedema likely had micro-clots, and patients with Lipedema treated with Natto reported a decrease in clothing size and fat distribution. Objective: Determine the effect of Natto on participants with Obesity and DM and in patients with Lipedema without DM. Materials and Methods: Group 1: Involved subjects with Obesity and DM. This was a double blinded, randomized controlled clinical trial over 3 months. A total of 17 female patients were recruited from a rural clinic. Nine received Natto 2,000 FU daily and eight received an identical placebo capsule daily. Fasting labs, questionnaires, bioimpedance, and anthropometric measurements were completed at Baseline and 3 months. Group 2: 42 women with Lipedema seen at a Fat Disorder Clinic. 21 received Natto and 21 did not. We compared for weight only from the day Nattokinase was started until follow-up, which varied from 4 months to 1 year 8 months. Results: Group 1: After 3 months, there was no difference in weight loss in both groups. Per Bioimpedance, more subjects lost water weight in the Natto group (63%) compared to Placebo (33%). More subjects in the Natto group had a decrease in HbA1c (43%) compared to Placebo (22%), with average decrease in the Natto group of 0.9%. Also, more subjects in the Natto group had lower fasting insulin levels (75% vs 22%), lower fasting glucose level (50% vs 22%) and lower HOMA index (63% vs 22%). Group 2: 57% of patients in the Natto group lost weight compared to only 33% of patients not on Natto. Conclusions: In participants with obesity and DM, regardless of weight loss, metabolic health improved after taking Natto for 3 months. Higher percentage of subjects in the treated group had improved HbA1c, fasting Insulin, glucose, and HOMA score. We hypothesize that if treatment time was beyond 3 months, further metabolic improvement would be noted, indicating that Natto could have potential as an adjunct to DM care. The difference in weight loss between Metabolic Obesity and Lipedema reflects the difference in adipose tissue, likely differing in etiology and pathophysiology. Further studies are needed to evaluate long term benefits of Natto, including larger and longer randomized controlled trials, and assessment of clotting factors.
Diabetic Ketoacidosis (DKA) is a life - threatening complication and must be diagnosed and treated promptly and aggressively. The classic triad of DKA is hyperglycemia (Blood Glucose (BG) >250mg/dl; anion gap metabolic acidosis (pH <7.30 and bicarbonate <18mEq/L); and ketonemia. With Food and Drug Administration (FDA) approval of the sodium - glucose transporter 2 inhibitors (SGLT2i), DKA can occur with BG levels below 200mg/dl and has been defined as Euglycemic DKA (EuDKA). Due to the absence of hyperglycemia, the diagnosis of EuDKA is challenging and often delayed. This 60-year-old diabetic male, treated with Empagliflozin and pioglitazone, presented with diarrhea and abdominal pain, which started 20 days ago. He was admitted with dehydration and diagnosis of colitis. On admission laboratory evaluation revealed metabolic acidosis with elevated anion gap of 18mEq/L, bicarbonate of 19mEq/L, and BG of 146mg/dL. There was no history of ingestion of alcohol, salicylates, methanol, ethylene glycol and nothing to suggest lactic acidosis. The plasma creatinine was 0.79mg/dl. On the following day, he developed an increase in the anion gap to 22mEq/L and further decrease in bicarbonate to 13mEq/L, and serum ketones were detected. The patient was treated for EuDKA in ICU with intravenous insulin, dextrose (to prevent hypoglycemia), and normal saline with resolution of his symptoms and EuDKA in 3 days. With the widespread use of SGLT2i, physicians need to have a high suspicion of EuDKA in patients who present with an unexplained anion gap acidosis without or only modest elevation in BG concentration.
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