Lipoedema – myths and facts, Part 5^[*]

Abstract

The four previous articles in this series addressed the myths and facts surrounding lipoedema. We have shown that there is no scientific evidence at all for the key statements made about lipoedema – which are published time and time again. The main result of this “misunderstanding” of lipoedema is a therapeutic concept that misses the mark. The patient’s real problems are overlooked.

The national and especially the international response to the series, which can be read in both German and English, has been immense and has exceeded all our expectations. The numerous reactions to our articles make it clear that in other countries, too, the fallacies regarding lipoedema have led to an increasing discrepancy between the experience of healthcare workers and the perspective of patients and self-help groups, based on misinformation mostly generated by the medical profession.

Parts 1 to 4 in this series of articles on the myths surrounding lipoedema have made it clear that we have to radically change the view of lipoedema that has been held for decades. Changing our perspective means getting away from the idea of “oedema in lipoedema” – and hence away from the dogma that decongestion is absolutely necessary – and towards the actual problems faced by our patients with lipoedema. Such a paradigm shift in a disease that has been described in the same way for decades cannot be left to individuals but must be put on a much broader footing. For this reason, the lead author of this series of articles invited renowned lipoedema experts from various European countries to discussions on the subject. Experts from seven different countries took part in the two European Lipoedema Forums, with the goal of establishing a consensus. The consensus reflects the experts’ shared view on the disease, having scrutinized the available literature, and having taken into account the many years of clinical practice with this particular patient group. Appropriate to the clinical complexity of lipoedema, participants from different specialties provided an interdisciplinary approach. Nearly all of the participants in the European Lipoedema Forum had already published work on lipoedema, had been involved in drawing up their national lipoedema guidelines, or were on the executive board of their respective specialty society.

In this fifth and final part of our series on lipoedema, we will summarise the relevant findings of this consensus, emphasising the treatment of lipoedema as we now recommend it. As the next step, the actual consensus paper “European Best Practice of Lipoedema” will be issued as an international publication.

Instead of looking at the treatment of oedema, the consensus paper will focus on treatment of the soft tissue pain, as well as the psychological vulnerability of patients with lipoedema. The relationship between pain perception and the patient’s mental health is recognised and dealt with specifically. The consensus also addresses the problem of self-acceptance, and this plays a prominent role in the new therapeutic concept. The treatment of obesity provides a further pillar of treatment. Obesity is recognised as being the most common comorbid condition by far and an important trigger of lipoedema. Bariatric surgery should therefore also be considered for patients with lipoedema who are morbidly obese. The expert group upgraded the importance of compression therapy and appropriate physical activity, as the demonstrated anti-inflammatory effects directly improve the patients’ symptoms. Patients will be provided with tools for personalised self-management in order to sustain sucessful treatment. Should conservative therapy fail to improve the symptoms, liposuction may be considered in strictly defined circumstances.

The change in the view of lipoedema that we describe here brings the patients’ actual symptoms to the forefront. This approach allows us to focus on more comprehensive treatment that is not only more effective but also more sustainable than focusing on the removal of non-existent oedema.

Key words

lipoedema - paradigm shift - european consensus - therapy

Schlüsselwörter

Lipödem - Paradigmenwechsel - Europäischer Konsensus - Therapie

^* All authors share the first authorship.

• References

• 1 Bertsch T, Erbacher G. Lipödem – Mythen und Fakten Teil 2. Phlebologie 2018; 47: 120-126
• 2 Bertsch T, Erbacher G. Lipödem – Mythen und Fakten Teil 1. Phlebologie 2018; 47: 84-92
• 3 Bertsch T, Erbacher G. Lipödem – Mythen und Fakten Teil 3. Phlebologie 2018; 47: 188-197
• 4 Schreiner L. Einfluss der bariatrischen Operation auf die Erkrankung Lipödem. Dissertation an der Universitätsklinik Freiburg 2019; noch unveröffentlicht
• 5 Bertsch T, Erbacher G. Lipödem – Mythen und Fakten Teil 4. Phlebologie 2019; 48: 47-56
• 6 Spahn J. Liposuktion soll Kassenleistung werden. Abrufbar unter: htps://www.bundesgesundheitsministerium.de/lipoedem.html
• 7 Aerzteblatt.de. Brief an Spahn: G-BA bietet Liposuktion bei Lipödem als befristete Kassenleistung an. 25.1.2019. Abrufbar unter: https://www.aerzteblatt.de/nachrichten/100656/Brief-an-Spahn-G-BA-bietet-Liposuktion-bei-Lipoedem-als-befristete-Kassenleistung-an
• 8 Faerber G, Bertsch T. Stellungnahme der Deutschen Gesellschaft für Lymphologie zur aktuellen Diskussion um die Liposuktion – Schreiben an Prof. Hecken, Vorsitzender des Gemeinsamen Bundesausschusses. Abrufbar unter: https://www.dglymph.de/aktuelles/
• 9 Teilnehmer des 1^st and 2^nd European Lipoedema Forum in Hamburg, als Co-Autoren genannt
• 10 Ruktowki J, Davis KE, Scherer PE. Mechanisms of Obesity and Related Pathologies: The Macro- and Microcirculation of Adipose Tissue. FEBS Journal 2009; 276 (20) 5738-5746
• 11 Stulnig T. Adipositas und die Entzündung des Fettgewebes. Austrian Journal of Clinical Endocrinology and Metabolism 2009; 2 (03) 17-21
• 12 Mancuso P. The role of adipokines in chronic inflammation. Immotargets Ther 2016; 5: 47-56
• 13 Pou KM, Massaro JM, Hoffmann U. Visceral and Subcutaneous Adipose Tissue Volumes Are Cross-Sectionally Related to Markers of Inflammation and Oxidative Stress. The Framingham Heart Study. Circulation published online Aug 20 2007
• 14 Halberg N, Khan T, Trujillo ME. Hypoxia-inducible factor 1alpha induces fibrosis and insulin resistance in white adipose tissue. Mol Cell Biol 2009; 29 (16) 4467-4483
• 15 Fujisaka S, Usui I, Ikutani M. Adipose tissue hypoxia induces inflammatory M1 polarity of macrophages in an HIF-1α-dependent and HIF-1α-independent manner in obese mice. Diabetologia 2013; 56 (06) 1403-1412
• 16 Kayserling E. Zur Histologie des Lipödems. In Strößenreuther RHK. Lipödem und Cellulitis sowie andere Erkrankungen des Fettgewebes. Köln: Viavital Verlag; 2001
• 17 Crescenzi R, Marton A, Donahue PMC. Tissue Sodium Content is Elevated in the Skin and Subcutaneous Adipose Tissue in Women with Lipedema. Obesity 2018; 26 (02) 316
• 18 Al-Ghadban S. Dilated Blood and Lymphatic Microvessels, Angiogenesis, Increased Macrophages, and Adipocyte Hypertrophy in Lipedema Thigh Skin and Fat Tissue. Journal of Obesity 2019 ; Article ID 8747461
• 19 Walker AK, Kavelaars A, Hejnen CJ. Neuroinflammation and Comorbidity of Pain and Depression. Pharmacol Rev 2014; 66 (01) 80-101
• 20 Hotamisligil G, Wellen K. Obesity-induced inflammatory changes in adipose tissue. The Journal of Clinical Investigation. Abrufbar unter: https://www.jci.org/articles/view/20514
• 21 Butler DS, Moseley GL. Schmerzen verstehen. 3.. Aufl. Berlin, Heidelberg: Springer; 2016. Englische Fassung: Butler DS, Moseley GL. Explain Pain. Second Edition (2013) Noigroup Publications, Adelaide Australia
• 22 Hermesdorf M, Berger K, Baune BT. Pain Sensitivity in Patients With Major Depression: Differential Effect of Pain Sensitivity Measures, Somatic Cofactors, and Disease Characteristics. Journal of Pain 2016; 17 (05) 606-616 . doi:10.1016/j.jpain.2016.01.474. Epub 2016 Feb 9
• 23 Klinger R. Psychische Schmerzmodulation. Schmerz 2017; 31: 91-92 . doi:10.1007/s00482-017-0213-2
• 24 Briest J, Bethge M. Der Einfluss von Katastrophisieren auf den Effekt von Depressivität auf Schmerz und körperliche Funktion. Der Schmerz 2017; 2: 159-166 . Abrufbar unter: https://doi.org/10.1007/s00482-016-0172-z
• 25 Baerwald C. Einfluss von geringem und schwerem Stress auf eine Rheumaerkrankung. Deutsche Rheuma Liga. Abrufbar unter: https://www.rheuma-liga.de/stress/
• 26 Miller AH. Five Tings to Know About Inflammation and Depression. Psychiatric Times 2018 35 (04). https://www.psychiatrictimes.com/special-reports/five-things-know-about-inflammation-and-depression/page/0/1
• 27 Slavich GM, Way BM, Eisenberger NI. et al. Neural sensitivity to social rejection is associated with inflammatory responses to social stress. Proc Natl Acad Sci USA 2010; 107: 14817-14822
• 28 Hori H, Kim Y. Inflammation and posttraumatic stress disorder. Psychiatry Clin Neurosci 2019 DOI: 10.1111/pcn.12820 [Epub ahead of print]
• 29 World Health O. ICF: International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001
• 30 Stucki G, Grimby G. Applying the ICF in medicine. J Rehabil Med 2004; 44 (Suppl.): 5-6
• 31 Richtlijn lipoedeem. In. Utrecht: NVDV; 2014
• 32 Halk AB, Damstra RJ. First Dutch guidelines on lipedema using the international classification of functioning, disability and health. Phlebology 2017; 32 (03) 152-159
• 33 Netherlands HCot. Physical Activity Guidelines. In: Ministry of Health WaS. , ed. The Hague. 2017
• 34 Lorig KR, Sobel DS, Stewart AL. et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999; 37 (01) 5-14
• 35 Jansen D, Spreeuwenberg P, Heijmans M. Ontwikkelingen in de zorg voor chronisch zieken. Rapportage 2012. Utrecht: NIVEL; 2012
• 36 Ridner SH, Fu MR, Wanchai A. et al. Self-management of lymphedema: a systematic review of the literature from 2004 to 2011. Nurs Res 2012; 61 (04) 291-299
• 37 van Esch-Smeenge J, Damstra RJ, Hendrickx AA. Muscle strength and functional exercise capacity in patients with lipedema and obesity: a comparative (obeservational) study. Journal of Lymphoedema 2017; 12 (01) 27-31
• 38 Linton SJ, Hellsing AL, Andersson D. A controlled study of the effects of an early intervention on acute musculoskeletal pain problems. Pain 1993; 54 (03) 353-359
• 39 Ostelo RW, de Vet HC, Berfelo MW. et al. Effectiveness of behavioral graded activity after first-time lumbar disc surgery: short term results of a randomized controlled trial. Eur Spine J 2003; 12 (06) 637-644
• 40 Koke A, van Wilgen P. Graded Activity. Vol 1. Houten: Bohn Stafleu van Loghum; 2007
• 41 Noland MP. The effects of self-monitoring and reinforcement on exercise adherence. Res Q Exerc Sport 1989; 60 (03) 216-224
• 42 Veenhof C, Köke AJ, Dekker J. et al. Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: A randomized clinical trial. Arthritis Rheum 2006; 55 (06) 925-934
• 43 Krüger K. Inflammation during Obesity – Pathophysiological Concepts and Effects of Physical Activity. Dtsch Z Sportmed 2017; 68: 163-169
• 44 Ringseis R, Eder K, Mooren FC. Metabolic signals and innate immune activation in obesity and exercise. Exerc Immunol Rev 2015; 21: 58-68
• 45 Wegner M, Helmich I, Machado S. et al. Effects of Exercise on Anxiety and Depression Disorders: Review of Meta- Analyses and Neurobiological Mechanisms. CNS & neurological disorders drug targets 2014; 13: 1002-1014
• 46 Rief W, Bleichhardt G, Dannehl K. et al. Comparing the efficacy of CBASP with two versions of CBT for depression in a routine care center: A randomized clinical trial. Psychotherapy and Psychosomatics 2018; 87 (03) 164-178
• 47 Langendoen SI, Habbema L, Nijsten TE. et al. Lipoedema: from clinical presentation to therapy. A review of the literature. The British journal of dermatology 2009; 161 (05) 980-986
• 48 Reich-Schupke S, Altmeyer P, Stücker M. Thick legs – not always lipedema. J Dtsch Dermatol Ges 2013; 11 (03) 225-233
• 49 Wagner EH. Chronic disease management: what will it take to improve care for chronic illness?. Eff Clin Pract 1998; 1 (01) 2-4
• 50 Bandura A, Adams NE. Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research 1977; 1 (04) 287-310
• 51 Konschake W, Valesky E, Stege H. Evidenz der Kompressionstherapie. Der Hautarzt 2017; 68: 625-631
• 52 Kramer WJ, Volek J, Bush A. Influence of compression hosiery on physiological responses to standing fatigue in women. Med Sci Sports Exerc 2000; 32 (11) 1849-1858
• 53 Altintas A, Gehl B, Aust M. Impact of compression therapy on local microcirculation and histomorphology in venous leg ulcers. Phlebologie 2011; 40: 9-14
• 54 Ligi D, Croce L, Mannello F. Inflammation and compression: the state of art. Veins and Lymphatics 2016. Verfügbar unter: https://www.pagepressjournals.org/index.php/vl/article/view/5980
• 55 Beidler SK, Douillet CD, Berndt DF. Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. J Vasc Surg 2009; 49 (04) 1013-1020
• 56 Grenier E, Gehin C, Mc Adams E. Effect of compression stockings on cutaneous microcirculation: Evaluation based on measurements of the skin thermal conductivity. Phlebology 2016; 31 (02) 101-105
• 57 Mayrovitz HN, Delgado M, Smith J. Compression bandaging effects on lower extremity peripheral and sub-bandage skin blood perfusion. Ostomy Wound Manage 1998; 44 (03) 56-60
• 58 Flore R, Geradino L, Santoliquido A. Reduction of oxidative stress by compression stockings in standing workers. Occupational Medicine 2007; 57 (05) 337-341
• 59 Is Hak WW, Wen RY, Naghdechi L. Pain and Depression: A Systematic Review. Harv Rev Psychiatry 2018; 26 (06) 352-363 . doi:10.1097/HRP.0000000000000198
• 60 Swami V. The attractive female body weight and female body dissatisfaction in 26 countries across 10 world regions: results of the international body project I. Pers Soc Psychol Bull 2010 Mar 36 (03) 309-325 . doi:10.1177/0146167209359702
• 61 Schuck K, Munsch S, Schneider S. Body image perceptions and symptoms of disturbed eating behavior among children and adolescents in Germany. Child Adolesc Psychiatry Ment Health 2018; 12: 10 . https://doi.org/10.1186/s13034-018-0216-5
• 62 Häuser W, Schmutzer G, Brähler E. et al. Maltreatment in childhood and adolescence—results from a survey of a representative sample of the German population. Dtsch Arztebl Int 2011; 108 (17) 287-294 . doi:10.3238/arztebl.2011.0287
• 63 Egle U, Egloff N, von Känel R. Stressinduzierte Hyperalgesie (SIH) als Folge von emotionaler Deprivation und psychischer Traumatisierung in der Kindheit. Konsequenzen für die Schmerztherapie. Der Schmerz 2016; 6. https://doi.org/10.1007/s00482-016-0107-8
• 64 Bachem R, Lorenz L, Köllner V. Kleine Traumata und das neue Konzept der Anpassungsstörung. PID 2019; 20 (02) 37-41
• 65 Louw A, Zimney K, Puentedura EJ. et al. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract 2016; 32 (05) 332-355
• 66 Louw A, Zimney K, O’Hotto C. et al. The clinical application of teaching people about pain. Physiother Theory Pract 2016; 32 (05) 385-395
• 67 Wijma AJ, van Wilgen CP, Meeus M. et al. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiother Theory Pract 2016; 32 (05) 368-384
• 68 Zanini S, Voltolini A, Gragnano G. et al. Changes in Pain Perception following Psychotherapy: The Mediating Role of Psychological Components. Pain Res Manag 2018; 2018: 8713084 . doi:10.1155/2018/8713084. eCollection 2018. PMID: 29849850
• 69 Tesarz J, Leisner S, Gerhardt A. et al. Effects of eye movement desensitization and reprocessing (EMDR) treatment in chronic pain patients: a systematic review. Pain Med 2014; 15: 247-263 . doi:10.1111/pme.12303
• 70 https://www.dgppn.de/leitlinien-publikationen/leitlinien.html
• 71 Faerber F, Rosendahl J. The association between resilience and mental health in the somatically ill—a systematic review and meta-analysis. Dtsch Arztebl Int 2018; 115: 621-627 . doi:10.3238/arztebl.2018.0621
• 72 Bertsch T, Martin KP. Adipositasprävalenz unter Lipödempatientinnen in einer kassenärztlichen lymphologischen Ambulanz im Jahr 2015. (unveröffentlichte Daten)
• 73 Bosman J. Lipoedema: Poor knowledge, neglect or disinterest?. Journal of Lymphoedema 2011; 6 (02) 109-111
• 74 Child AH. Lipedema: an inherited condition. Am J Med Genet A 2010; 152A [phone]
• 75 Stunkard A. The Results of Treatment for Obesity. A Review of the Literature and Report of a Series. AMA Arch Intern Med 1959; 103 (01) 79-85
• 76 Bennett W, Gurin J. The Dieter’s Dilemma: Why Diets Are Obsolete–the New Setpoint Theory of Weight Control. New York: Basic Books; 1982
• 77 Cogan J, Rothblum E. Outcomes of weight-loss Programms. Genetic, Social and General Psychology Monographs 1993; 118: 4
• 78 Perri MG, Fuller PR. Sucess and failure in the treatment of obesity: Where do we go from here?. Medicine, Exercise, Nutrition and Health 1995; 4: 255-272
• 79 Hensrud DD, Weinsier RL. A prospective study of weight maintenance in obese subjects reduced to normal body weight without weight-loss training. American clinical Nutrtion 1994; 60 (05) 688-694
• 80 Mann T, Tomiyama AJ, Westling E. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol 2007; 62 (03) 220-233
• 81 Nordmann A, Briel M, Keller U. Effects of low carb vs low fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Internal Med 2006; 166: 8
• 82 Fildes A, Charlton J. Probability of an obese person attaining normal body weight. American Journal of Public Health 2015; 105 (09) 54-59
• 83 Pietiläinen KH, Saarni SE, Kaprio J. Does Dieting Make You Fat?. International J of Obesity 2012; 36 (03) 456-464
• 84 Lustig R. Fat Chance – Beating the Odds against Sugar, Processed Food, Obesity, and Disease. New York: Hudson Street Press; 2012
• 85 Faerber G. Obesity and chronic Inflammation. Phlebologie 2018; 47: 55-65
• 86 Faerber G. Ernährungstherapie bei Lipödem und Adipositas – Ergebnisse eines leitliniengerechten Therapiekonzepts. Vasomed 2017; 29 (04) 122-123
• 87 Cohen PG. Aromatase, adiposity, aging and disease. The hypogonadal-metabolic-atherogenic- disease and aging connection. Med Hypotheses 2001; 56: 702-708
• 88 Ivandić A, Prpić-Krizevac I, Sucić M. et al. Hyperinsulinemia and sex hormones in healthy premenopausal women: Relative contribution of obesity, obesity type, and duration of obesity. Metabolism – Clinical and Experimental 1998; 47: 13-19
• 89 Nestler JE, Linda P, Powers LP. et al. A Direct Effect of Hyperinsulinemia on Serum Sex Hormone-Binding Globulin Levels in Obese Women with the Polycystic Ovary Syndrome. The Journal of Clinical Endocrinology & Metabolism 1991; 72: 83-89
• 90 Mizushima N, Noda T, Yoshimori T. et al. A protein conjugation system essential for autophagy. Nature 1998; 395: 395-398
• 91 Harvie M, Wright C, Pegington M. et al. The effect of intermittent energy and carbohydrate restriction vs. daily energy restriction on weight loss and metabolic disease risk markers in overweight women. British Journal of Nutrition 2013; 110: 1534-1547
• 92 Klempel MC, Kroeger CM, Bhutani S. Intermittent fasting combined with calorie restriction is effective for weight loss and cardioprotection in obese women. Nutr J 2012; 11: 98
• 93 Feinman RD, Pogozelski WK, Astrup A. et al. Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition 2015; 31: 1-13
• 94 Westman EC, Feinman RD, Mavropoulos JC. et al. Low-carbohydrate nutrition and metabolism. The American journal of clinical nutrition 2007; 86 (02) 276-284
• 95 Noakes T. Low-carbohydrate and high-fat intake can manage obesity and associated conditions: Occasional survey. South African Medical Journal 2013; 103 (11) 826-830
• 96 Hoenselaar R. Saturated fat and cardiovascular disease: The discrepancy between the scientific literature and dietary advice. Nutrition 2012; 28: 118-123
• 97 Sofi F, Buccioni A, Cesari F. et al. Effects of a dairy product (pecorino cheese) naturally rich in cis- 9, trans-11 conjugated linoleic acid on lipid, inflammatory and haemorheological variables: a dietary intervention study. Nutr Metab Cardiovasc Dis 2010; 20: 117-124
• 98 Ditschuneit HH, Flechtner-Mors M, Johnson TD. et al. Metabolic and weight-loss effects of a long-term dietary intervention in obese patients. Am J Clin Nutr 1999; 69 (02) 198-204
• 99 Cheng J, Gao J, Shuai X. et al. The comprehensive summary of surgical versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. Oncotarget 2016; 7: 39216-39230
• 100 Fried M, Yumuk V, Oppert JM. et al. Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg 2014; 24: 42-55
• 101 American College of Cardiology/American Heart Association Task Force on Practice Guidelines OEP. Executive summary: Guidelines (2013) for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society published by the Obesity Society and American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Based on a systematic review from the The Obesity Expert Panel, 2013. Obesity 2014; 22 (02) 5-39
• 102 Lee CM, Huxley RR, Wildman RP. et al. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. J Clin Epidemiol 2008; 6: 646-653
• 103 Gemeinsamer Bundesausschuss vom 20. Juli 2017. Tragende Gründe zum Beschluss des Gemeinsamen Bundesausschusses über eine Änderung der Richtlinie Methoden Krankenhausbehandlung: Liposuktion bei Lipödem. Abrufbar unter: https://www.g-ba.de/downloads/40-268-4488/2017-07-20_KHMe-RL_Liposuktion_TrG.pdf
• 104 Ärzteblatt.de. Liposuktion bei Lipödem: Bundessozialgericht weist Klage auf Kostenerstattung ab. Abrufbar unter: https://www.aerzteblatt.de/nachrichten/94709/Liposuktion-bei-Lipoedem-Bundessozialgericht-weist-Klage-auf-Kostenerstattung-ab
• 105 Task Force Lipödem/Liposuktion der Deutschen Gesellschaft für Phlebologie gemeinsam mit der Deutschen Gesellschaft für Lymphologie 2019; noch unveröffentlicht.
• 106 Zertifizierungsordnung. Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie. Abrufbar unter: http://www.dgav.de/zertifizierung/zertifizierungsordnung.html
• 107 Armer JM, Brooks CW, Stewart BR. Limitations of self-care in reducing the risk of lymphedema: supportive-educative systems. Nurs Sci Q 2011; 24 (01) 57-63
• 108 van der Vlegel-Brouwer W. Integrated healthcare for chronically ill. Reflections on the gap between science and practice and how to bridge the gap. Int J Integr Care 2013; 13: e019
• 109 Barr VJ, Robinson S, Marin-Link B. et al. The Expanded Chronic Care Model: An Integration of Concepts and Strategiesfrom Population Health Promotion and the Chronic Care Model. Hospital Quarterly 2003; 7 (01) 73-82
• 110 McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007; 87 (03) 873-904
• 111 Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd. ed. Guilford Press; 2012
• 112 Lundahl B, Burke BL. The Effectiveness and Applicability of MotivationalInterviewing: A Practice-Friendly Review of Four Meta-Analyses. Journal of Clinical Psychology 2009; 65 (11) 1232-1245
• 113 Larry E, Beutler T, Harwood M. What Is and Can Be Attributed to the Therapeutic Relationship?. Journal of Contemporary Psychotherapy 2002; 32 (01) 25-33
• 114 Sutin AR, Terracciano A. Perceived weight discrimination and obesity. PLoS One 2013; 8 (07) e70048 . doi:10.1371/journal.pone.0070048. Print 2013
• 115 Stellungnahme zum Lipödem. Földiklinik Hinterzarten 2019; Abrufbar unter: https://www.foeldiklinik.de/assets/pdf/Lipoedem-Stellungnahme-190428.pdf
• 116 Svensk Förening För Lymfologi (SFL) – Nyheter. 2019; Lipödem, myter och fakta. Abrufbar unter: http://www.lymfologi.se/nyheter/lipodem-myter-och-fakta/
• 117 Ang S. Demystifying Lipoedema. Lymphedema Education Solutions 2019. Abrufbar unter: https://lymphoedemaeducation.com.au/2019/04/demystifying-lipoedema/
• 118 ILF Conference 2020. International Lymphoedema Framework. Abrufbar unter: https://www.lympho.org/2020-conference/
• 119 Schrader K. Rätselhaftes Lipödem – ein Kommentar. LymphForsch 2019; 23 (01) 49-55
• 120 Hirsch T, Schleinitz J, Faerber G. Ist die Differentialdiagnostik des Lipödems mittels hochauflösender Sonografie möglich?. Phlebologie 2018; 47: 182-187
• 121 Buchwald H, Estok R, Fahrbach K. et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009; 122: 248-256
• 122 Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass, Roux en-Y – 500 Patients: Technique and Results, with 3–60 months follow-up. Obes Surg 2000; 10: 233
• 123 Sugerman HJ, Wolfe L, Sica D. Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss. Ann Surg 2003; 237: 751-756
• 124 Rasheid S, Banasiak M, Gallagher SF. Bypass is an Effective Treatment for Obstructive Sleep Apnea in Patients with Clinically Significant Obesity. OBES SURG 2003; 13: 5
• 125 Courcoulas AP, Yanovski SZ, Bonds D. Long-term Outcomes of Bariatric Surgery: A National Institutes of Health Symposium. JAMA Surg 2014; 149 (12) 1323-1329
• 126 Arterburn DE, Olsen MK, Smith VK. Association Between Bariatric Surgery and Long-term Survival. JAMA 2015; 313 (01) 62-70
• 127 Sjöström L, Narbro K, Sjöström CD. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357: 741-752
• 128 Adams TD, Gress RE, Sherman MA. Long-term mortality after gastric bypass surgery. N Engl J Med 2007; 357: 753-761
• 129 Shubeck S, Dimick JB, Telem DA. Long-term Outcomes Following Bariatric Surgery. JAMA 2018; 319 (03) 302-303
• 130 Starke N. Der Lipödempodcast. Abrufbar unter: https://www.derlipoedempodcast.de
• 131 Garcia I. Lipödem – Ich bin mehr als meine Beine. Stuttgart. Trias-Verlag; 2018
• 132 Derogatis LR, Savitz KL. “The SCL-90-R and the Brief Symptom Inventory (BSI) in Primary Care”. In: Maruish ME. (ed.). Handbook of psychological assessment in primary care settings. Mahwah, NJ: Lawrence Erlbaum Associates; 2000: 297-334
• 133 Franke GH. Symptom-Checklist-90®-Standard. Hogrefe; 2014
• 134 Zigmond AS, Snaith RP. “The hospital anxiety and depression scale”. Acta Psychiatrica Scandinavica 1983; 67 (06) 361-370 . doi:10.1111/j.1600-0447.1983.tb09716.x. PMID 6880820
• 135 Bjelland I, Daal AA, Haug TT. “The validity of the Hospital Anxiety and Depression Scale. An updated literature review”. Journal of Psychosomatic Research 2002; 52 (02) 69-77 . doi:10.1016/s0022-3999(01)00296-3. PMID 11832252
• 136 Fairburn CG, Cooper Z, O’Connor ME. Eating Disorder Examination. (Edition 17.0D) 2014. Verfügbar unter: http://www.credo-oxford.com/7.2.html
• 137 Hilbert A, Tuschen-Caffier B, Ohms M. Eating Disorder Examination: Deutschsprachige Version des strukturierten Essstörungsinterviews. Diagnostica 2004; 50: 98-106
• 138 Hilbert A, Tuschen-Caffier B. Eating Disorder Examination-Questionnaire. Deutschsprachige Übersetzung. 2.. Auflage. Tübingen: dgvt Verlag; 2016
• 139 Funke F. Internet-based measurement with visual analogue scales: An experimental investigation (Internetbasierte Messungen mit visuellen Analogskalen: Eine experimentelle Untersuchung). Dissertation in Fach Psychologie an der Mathematisch-Naturwissenschaftlichen Fakultät der Eberhard Karls Universität Tübingen 13. August 2011
• 140 Morfeld M, Kirchberger I, Bullinger M. SF-36, Fragebogen um Gesundheitszustand. 2.. Aufl. Hogrefe; 2011
• 141 Bullinger M. Erfassung der gesundheitsbezogenen Lebensqualität mit dem SF-36-Health Survey. Bundesgesundheitsbl – Gesundheitsforsch – Gesundheitsschutz 2000; 43: 190 . https://doi.org/10.1007/s001030050034
• 142 Skevington SM, Lotfy M, O’Connell K. The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Quality of life Research 2004; 13 (02) 299-310
• 143 Gunzelmann T, Brähler E, Angermeyer C. et al. Deutschsprachige Version der WHO Instrumente zur Erfassung von Lebensqualität WHOQOL-100 und WHOQOL-BREFM. Zeitschrift für Medizinische Psychologie 2002; 11: 44-48
• 144 http://www.who.int/mental_health/evidence/who_qol_user_manual_98.pdf Accessed 20th September 2017