Weight Management

Weight Management

PEP Topic 
Lymphedema
Description 

Weight management involves the use of programmatic or informal strategies in which patients implement behaviors to lose weight or maintain an appropriate body weight. This is generally accomplished through diet and activity. Weight management has been evaluated in patients with cancer related to prevention and management of lymphedema.

Likely to Be Effective

Research Evidence Summaries

Ay, A.A., Kutun, S., & Cetin, A. (2014). Lymphoedema after mastectomy for breast cancer: importance of supportive care. South African Journal of Surgery (Suid-Afrikaanse Tydskrif Vir Chirurgie), 52, 41–44. 

doi: 10.7196/sajs.1908
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Study Purpose:

To evaluate the impact of rehabilitative, medical, and physical therapies or a lack of these interventions on the development of breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

This was a retrospective study of the medical records and follow-up forms of 5,064 women with breast cancer between 1995 and 2010. Preoperatively, all patients were instructed in risk reduction behaviors (no needles and no blood pressure measurements on the affected side). During the postoperative period, pressure dressings on the axillary fossa and flap region were used during the first five days. Venous cannulation was avoided in the involved arm during the first two postoperative years. Patients attended routine follow-up visits. Patients who received adjuvant radiotherapy also were treated in the axillary area. Cyclophosphamide, adriablastin, 5-fluorouracil, and docetaxel were used for first-line adjuvant chemotherapy. All patients were referred to physiotherapy and the rehabilitation clinic postoperatively. Patients were taught daily self-drainage massage techniques and flexibility and strength exercises. Patients were educated about lymphedema symptoms, skin care, and general protective measures, and they were given written materials.

Sample Characteristics:

  • N = 5,064
  • MEDIAN AGE = 51 years (range = 34–75 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Patients with stages 2 and 3 breast cancer 
  • OTHER KEY SAMPLE CHARACTERISTICS: Modified radical mastectomy with levels 1–3 axillary dissection; Stewart transverse incision; Cooper’s ligaments involved; axillary dissection included dissecting under the pectoralis minor muscle; exclusion criteria included limb trauma, vascular disease, thromboembolic events, neoadjuvant chemotherapy or radiotherapy, uncontrolled diabetes, cardiovascular disease, or history of serious infection or surgery on the affected side

Setting:

  • SITE: Single site    
  • SETTING TYPE: Not specified    
  • LOCATION: Turkey

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care

Study Design:

Retrospective, two-group design (physiotherapy group participated in physiotherapy and did exercises regularly, no physiotherapy group did not receive physiotherapy or did not do exercises regularly)

Measurement Instruments/Methods:

  • Difference in circumference measured pre- and postoperatively > 5%

Results:

Overall, 19.9% of patients developed lymphedema. It was significantly less common in patients who participated in physiotherapy than in those who did not (p <  0.001), and it was more common in patients with a body mass index (BMI, kg/m2) between 30–34.9 than in those with lower BMIs (p < 0.001).

Conclusions:

Educating patients about the risk factors (e.g., weight management) of lymphedema and referring them to postoperative physical therapy and rehabilitation clinics may be an important way to prevent postoperative lymphedema.

Limitations:

  • Risk of bias (no random assignment)
  • Other limitations/explanation: Retrospective design; single-site study

Nursing Implications:

Educating patients about the risk factors for developing lymphedema pre- and post-treatment is important. All patients who received aggressive surgeries and do not have lymphedema will benefit from referral to a physical therapy program to teach exercises. Nurses can teach risk reduction guidelines.

Shaw, C., Mortimer, P., & Judd, P.A. (2007). Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema. Cancer, 109(10), 1949–1956.

doi: 10.1002/cncr.22638
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Study Purpose:

To evaluate whether using dietary interventions could be beneficial in the treament of arm lymphedema in patients who have breast cancer-related lymphedema

Sample Characteristics:

  • The study sample (N =64) was comprised of female patients.
  • Patients were stratified by volume and treatment and then randomized to one of three groups.
    • Weight reduction with decreased calories to 1,000–1,200 a day
    • Low-fat diet without change in calories, reducing dietary fat to 20% of total calories
    • Control group without change from intake
  • Fifty-one patients completed the study.

Study Design:

The study used a randomized controlled trial design with two interventions and one control group.

Measurement Instruments/Methods:

  • The volume measurements were performed by lymphedema practitioners who were blinded to the intervention using a Perometer and a volume equation using circumference.
  • Arm circumference was measured every 4 cm.
  • Height and weight were measured.
  • Skin fold thickness was measured at four sites.

Results:

Results showed significant reduction in body weight (p = 0.006), body mass index (p = 0.008), and skin fold thickness measured at four sites (p = 0.044) in the weight-reduction and low-fat groups but not in the control group. There was a reduction in excessive arm volume over the 24 weeks but no significant difference between groups. There was a significant correlation between weight loss and a reduction in excess am volume irrespective of the dietary group (p < 0.002). Weight loss for the control, weight-reduction, and low-fat groups were 60%, 95%, and 76%, respectively. Weight reduction appears to be an effective means of assisting in the reduction of arm volume during the treatment of the lymphedema arm.

 

Conclusions:

A good study that identifies an important risk factor and intervention.

Limitations:

  • The study was ambitious and could have benefited from a simple weight-controlled study.
  • Patients used compression sleeves and bandages during the intervention; nevertheless, the patients were distributed throughout the groups.
  • Patients had poor adherence to diets.
  • Some patients who were instructed not to lose weight did.
  • The calorie intake of 1,000–1,200 per day is low for anyone.

Guideline/Expert Opinion

Lymphoedema Framework. (2006). International consensus: Best practice for the management of lymphoedema. London, UK: Medical Education Partnership. Retrieved from http://www.woundsinternational.com/pdf/content_175.pdf

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Purpose & Patient Population:

TYPES OF PATIENTS ADDRESSED: Sample not described

Type of Resource/Evidence-Based Process:

PROCESS OF DEVELOPMENT: Study utilized previous Cochrane Systematic reviews along with current references to a United Kingdom national consensus on standards of practice for people at-risk for, or who have, lymphedema (LE)

Evidence weighed using the following classification:
  • A = Clear research evidence
  • B = Limited supporting research evidence
  • C = Experienced common sense judgment.

Guidelines & Recommendations:

Recommended for Practice
 
Complete decongestive therapy
  • Patients with LE should receive a coordinated package of care appropriate to their needs (B).
Compression bandaging
  • Multilayer inelastic lymphedema bandaging (B)
  • Compression garments (C)
Management of infection: Cellulitis/erysipelas
  • Criteria for hospitalization
    • Signs of septicemia (e.g., high fever, hypotension, tachycardia, confusion, vomiting).
    • Continuing or deteriorating systemic signs with or without deteriorating local signs after 48 hours of antibiotic therapy.
    • Unresolved or deteriorating local signs with or without systemic signs after first- and second-line oral antibiotics.
    • Close medical follow-up
Exclude other causes of systemic infection, DVT, or dermatologic conditions such as eczema and contact dermatitis.
  • Before starting antibiotics
    • Swab any exudates, if present
    • Mark extent of rash and date edge
    • Note any painful or swollen regional lymph nodes
    • Obtain labs for ESR, CRP, WBC, and blood cultures.
Begin antibiotics as soon as possible (recommended for practice).
 
During bed rest, elevate limb, administer appropriate analgesia, and increase fluid intake.
 
Avoid simple lymphatic drainage (SLD) and manual lymphatic drainage (MLD). If tolerated, continue compression at a reduced level or switch from compression garments to MLLB.
 
Avoid long periods without compression.
 
Likely to be Effective
 
Manual lymphatic drainage (C) 
 
Prevention of infection: skin care 
  • Good skin care regimens should be implemented by patients and caregivers in the management of LE (B).
  • Use neutral pH soaps to avoid drying.
  • Apply emollients. 
  • Keep skin folds clean and dry.
  • Inspect skin for cuts, scrapes, abrasions, and insect bites.
  • Avoid scented products.
Benefits Balanced With Harm                                      

Exercise

  • Exercise/movement/elevation (C)
  • Breathing exercises (C) 

Prophylactic antibiotics: prevention of infection 

  • Patients are advised to travel with a two-week supply of antibiotics if they have a history of lymphedema. 
Effectiveness not Established

Intermittent pneumatic compression (C)

Simple lymphatic drainage (SLD)

Surgery (limited evidence, carefully selected patients may benefit, more research needed)

  • Surgical reduction
  • Bypass of lymphatic obstruction
  • Liposuction/lipectomy
Expert Opinion

Patient education 

  • People at risk of lymphedema should be identified early during routine assessment, monitored, and taught self-care (C). 
  • Patients and caregivers should be offered information about LE and its management.
  • Take good care of skin and nails.
  • Maintain optimal body weight (B).
  • Eat a balanced diet.
  • Avoid tight clothing, watches, and jewelry.
  • Avoid extremes in temperature.
  • Use sunscreen and insect repellent.
  • Wear compression garments if prescribed.
  • Undertake exercise and diaphragmatic breathing exercises.
  • Wear comfortable, supportive shoes.
  • Risk factors for upper extremity lymphedema 
  • Surgery of breast with axillary node dissection
  • Scar formation, radiodermatitis from postoperative radiotherapy
  • Radiotherapy to breast
  • Drainage or wound complications
  • Cording or seroma formation
  • Obesity
  • Congenital predisposition
  • Trauma to affected extremity (venipuncture, injection, BP)
  • Taxane chemotherapy
  • Insertion of a pacemaker
  • AV fistula for dialysis
  • Living in or visiting a lymphatic filariasis endemic area
  • Risk factors for lower extremity lymphedema
  • Inguinal node dissection
  • Postoperative pelvic radiotherapy
  • Recurrent soft-tissue infection
  • Obesity
  • Vein stripping or vein harvesting
  • Genetic predisposition
  • Intrapelvic or intra-abdominal tumor
  • Thrombophlebitis
  • Poor nutritional status
  • Chronic skin disorders or inflammation
  • Any unresolved asymmetric edema
  • Concurrent illness
  • Immobilization or prolonged limb dependency
  • Living in or visiting a lymphatic filariasis endemic area
Measurement 
  • Accurate assessment including staging (C)
    • Measurement  of LE
    • Assessment of skin
    • Assessment of vascular integrity
  • Patients with LE should receive psychological screening to identify those who require help to cope with the condition and those who require specialist intervention (C).
 

 

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