Nutrition in Lipedema

1. Nutrition Workshop — Lipedema Evolution 2026

• Obesity or Lipedema? Opening and Screening AlgorithmDanilo Dib opens the workshop arguing that if lipedema treatment is multidisciplinary, each professional's knowledge needs to be as well. The nutritionist does not diagnose, but needs to recognize signs and symptoms, refer, and treat in parallel. The lesson presents a practical screening algorithm for the clinic (confirmed diagnosis or not, with or without associated overweight or obesity) and discusses the paradox of the scale: asymmetric loss, the fact that a caloric deficit is necessary but insufficient, and the chronic frustration of those who lose weight in the trunk but not in the legs. It closes with managing expectations, the importance of treating symptoms before aesthetics, and removing the patient's guilt. Chapters 00:00 Big Picture: Why Knowledge Needs to Be Multidisciplinary 01:35 Sensitivity and Rapport With the Lipedema Patient 03:22 The Nutritionist's Proximity and Adherence to the Dietary Plan 04:59 The Nutritionist Does Not Diagnose: The Role of Referral 05:25 Screening Algorithm: Obesity, Lipedema, or Both 08:13 The Paradox of the Scale: Asymmetric Loss and Caloric Deficit 09:53 Clinical Case: Response in the Trunk Versus the Lower Limbs 10:42 Managing Expectations and Body Type 12:16 Symptoms Under Control: The Patient's Perception of Value 13:08 The Psychology of Diagnosis: Removing the Guilt 13:57 Summary and Closing14min
• Ketogenic Diet in Lipedema: Principles, Practical Application, and Common MistakesMany lectures at the congress cited evidence for the ketogenic diet in lipedema, but none explained how to do it. Danilo Dib fills that gap with a practical lesson: history (Mayo Clinic, epilepsy, Di Pasquale's Metabolic Diet), the pillars (20 to 50 g of carbohydrate from measured vegetables and berries; controlled protein to avoid gluconeogenesis; quality fat, not unlimited), signs and symptoms of ketosis, use of urine test strips, and the most common mistake: overshooting calories with fat. The lesson includes the oil composition table, a discussion of omega-6 and the refining of vegetable oils, management of constipation (with a warning for patients on GLP-1), the difference between acute and chronic use, how to interpret the initial loss of water and glycogen, assessment with bioimpedance, photos, measurements, and BodyMetrix ultrasound, what to avoid (processed meats, saturated fats, junk keto), the recommended dietary base, and the carb refeed strategy with clean free meals. Chapters 00:00 Why explain the ketogenic diet to the patient 00:49 Origin and history: Mayo Clinic, epilepsy, and the Metabolic Diet 03:15 Pillar 1: carbohydrates between 20 and 50 g, measured vegetables, and berries 04:52 Pillar 2: controlled protein and gluconeogenesis 06:33 Signs of ketosis: fruity breath, diarrhea, headache, and adaptation 07:23 Adherence: going out of and back into ketosis, social events 08:59 Diagnosing ketosis: urine test strips 09:47 Calorie control: fat is not unlimited 11:23 Fat quality: oil composition table 14:51 Discussion: omega-6, refining of vegetable oils, and melting point 18:05 Constipation, fiber, and the warning for patients on GLP-1 20:27 When to use it: anti-inflammatory shock (acute) or chronic maintenance 21:14 Initial weight loss: water and glycogen 22:03 Body assessment: bioimpedance, photos, measurements, and BodyMetrix ultrasound 26:46 What to avoid: processed meats, saturated fats, and junk keto 27:35 Diet base: berries, olive oil, avocado, and nuts 28:22 Metabolic refeed: cyclical ketogenic diet 30:43 Clean free meal versus junk free meal 32:14 Study guide: meta-analysis, the book 'Dieta Cetogênica Estratégica', and livestream33min
• The Role of Pathology in Integrative Medicine: Food Intolerance, IgG and MetainflammationDr. Paulo Grimaldi starts from the genome (genes produce enzymes, enzymes digest foods) to explain why some foods are incompatible with each organism. He classifies adverse reactions to foods (toxic, non-toxic, enzymatic, immunological), distinguishes IgE allergy (immediate, 4 to 5 hours) from delayed IgG hypersensitivity (4 to 6 days) and shows, with slides and diagrams, the functional anatomy of the small intestine: villi, enterocytes, cell junctions, glycocalyx and the 80% of the immune system that lives there. When there are not enough macrophages to phagocytose the antigen-antibody complexes, they are deposited in the endothelium and generate the inflammation that produces signs and symptoms in any organ. The lesson moves on to the modern concept of metainflammation, the components of inflammation, the vicious cycle of leaky gut, oxidative stress and insulin resistance, and presents the York study (5,286 patients, 76% improvement, 92% relapse upon reintroduction), the mechanics of the IgG test (222 foods in duplicate, traffic-light results), pre-test precautions (corticosteroids and pregnancy) and the ranking of the most incompatible foods in Brazil and the US. Chapters 00:00 Genome, Proteins and Enzymes: Why Some Foods Are Harmful 02:37 Concept: Adverse Reactions to Foods (Toxic, Immunological, Non-Immunological) 04:17 Lactose Intolerance: Enzyme Deficiency, No Immune Reaction 05:06 IgE (Immediate Hypersensitivity) Versus IgG (Delayed, 4 to 6 Days) 07:29 Antigen, Antibody, Plasma Cell and Immunological Memory 09:55 Anatomy of the Small Intestine: Absorption Versus Microbiota 11:31 Villi, Enterocytes and the Virtual Space (Leaky Gut) 13:57 Glycocalyx, Lymphocytes and the 80% of the Immune System in the Gut 16:26 Cell Junctions: Tight Junctions, Adherens Junctions and Desmosomes 17:16 The Intestinal Barrier and Gluten: Macrophages and Antigen-Antibody Complexes 19:42 Deposition in the Endothelium: The Origin of Signs and Symptoms 21:19 Mild and Chronic Symptoms; Corticosteroids and Pregnancy Invalidate the Test 22:52 Metainflammation: From the Classical to the Modern Concept 26:03 Components of Inflammation: Vessels, Leukocytes and Chemical Mediators 29:13 Outcomes: Restitutio ad Integrum, Scarring and Chronic Inflammation 30:51 Properties of Immunoglobulin G and Phagocytosis 34:06 Vicious Cycle: Leaky Gut, Oxidative Stress and Insulin Resistance 35:48 Dysbiosis and Associated Diseases 36:37 Signs and Symptoms of Food Intolerance by System 38:15 York Study: 5,286 Patients, 76% Improvement, 92% Relapse 40:41 How the IgG Test Is Done: 222 Foods in Duplicate and Traffic-Light Results 43:06 Patient Testimonials 43:54 Top 10 Incompatible Foods: Brazil Versus the US 45:31 Summary of the Pathophysiology 46:19 Conclusion and the Six Pillars of Lifestyle49min
• Anti-Inflammatory and Strategic Diet for Lipedema: Far Beyond FatLuana presents lipedema as a condition that demands a lifestyle change, not a diet to lose weight and then return to previous habits. Starting from the pathophysiological web (local insulin resistance, lymphatic dysfunction, chronic inflammation, capillary fragility), she shows why the diet needs to be low-carb and anti-inflammatory, why strength training comes before aerobic exercise, and why supplementation is part of the plan. She critiques the traditional approach (800 kcal diets, daily fasting), which reduces muscle mass and the conversion of T4 to T3, and discusses the responsible use of tirzepatide in partnership with the physician. She structures treatment around four metabolic goals and details the estrobolome-gut axis: non-fermentable fibers (guar gum, acacia gum, psyllium), digestive enzymes and bile salts before probiotics, and precautions regarding SIBO. She shares her practical arsenal (omega-3 in triglyceride form, polyphenols, curcumin, quercetin, resveratrol, NAC, glutamine, creatine, vitamin D, magnesium), food rotation with reintroduction every 3 days, the clinical history she uses in her practice, exercise prescription according to pain and functional capacity, and the critical laboratory tests, including hormonal ones. Chapters 00:00 Lifestyle change, not a weight-loss diet 00:51 The pathophysiological web: local insulin resistance, lymphatic dysfunction and inflammation 02:30 Low-carb without ketosis; strength training before aerobic exercise 04:08 Insulin as an inflammatory hormone; antioxidants and supplementation 05:50 Traditional versus strategic approach: 800 kcal diets and daily fasting 06:39 T4-to-T3 conversion and subclinical hypothyroidism 08:18 GLP-1 analogs: dose, appetite and the physician-nutritionist partnership 11:38 The four metabolic goals: inflammation, muscle mass, edema and blood glucose 12:27 Fiber (30 g/day) and the estrobolome: estradiol reabsorption in dysbiosis 14:08 Non-fermentable fibers: guar gum, acacia gum and psyllium 14:57 Why not to start with a probiotic 15:45 Digestive history: digestive enzymes and bile salts 18:14 When to introduce a probiotic; caution with SIBO 19:51 Bioactives: resveratrol, curcumin, pycnogenol, alpha-lipoic acid and NAC 21:27 Hydration: 35 to 40 ml/kg 22:15 Preserving muscle mass; reducing ultra-processed foods and sodium 23:55 Modulating blood glucose: insulin, sodium and strength exercise (GLUT4) 25:12 Omega-3: dose, EPA and triglyceride form 26:25 Polyphenols in the diet: organic berries, cocoa, green tea and turmeric 28:04 Starting with the basics before the IgG test 28:55 Minimum protein of 1.6 g/kg 29:46 Food rotation and reintroduction at 3-day intervals 32:09 Estrobolome: the hidden gut-lipedema axis 33:49 Glutamine, compounded fiber and yeast 36:19 Supplementation strategies: quercetin, creatine, vitamin D, magnesium and CPT-1 38:04 Clinical history: sleep, restrictive diets, binge eating, menstrual cycle and functional capacity 39:42 Exercise: water aerobics as a bridge, strength training as the priority 41:15 Critical laboratory tests: blood glucose, inflammation, nutritional profile and hormones 42:51 Conclusion: treating lipedema means modulating inflammation and restoring quality of life44min
• Metabolism in Lipedema: Energy Expenditure, Body Composition Assessment and Macronutrient CalculationA continuation of the anti-inflammatory diet lesson, focused on numbers. Luana shows why the same weight does not mean the same metabolism and how very restrictive diets or high doses of GLP-1 trigger the cycle of functional hypometabolism: muscle loss, drops in T3 and NEAT, increased hunger and cortisol, fluid retention and inflammation. She compares assessment methods (skinfold measurements, which are inadequate in lipedema; bioimpedance with preparation; BodyMetrix ultrasound as the gold standard because it is not affected by edema; indirect calorimetry) and presents the rule-of-thumb formula for energy expenditure according to activity level. She details the ranges for protein (1.6 to 2.2 g/kg, with a maximum of 1.8 in SIBO), carbohydrate (1 to 5 g/kg, distributed around training or at the meal with the greatest hunger, with resistant starch and glycemic index by time of day) and fat (0.8 to 1.2 g/kg, up to 10% saturated), and discusses the role of exercise in mitochondrial biogenesis, fasting as an intermittent strategy, sleep and fatigue. She concludes with the new paradigm: the patient with lipedema does not need to learn to eat less; she needs to produce energy efficiently. Chapters 00:00 Same weight is not the same metabolism 00:51 The functional hypometabolism cycle: restriction, GLP-1, T3, NEAT and cortisol 02:30 How to assess: skinfold measurements, bioimpedance with preparation and BodyMetrix ultrasound 04:57 BodyMetrix by region, frequency of use and indirect calorimetry 06:34 Rule-of-thumb formula: 20 to 32 kcal/kg according to activity 08:14 Protein: 1.6 to 2.2 g/kg and the 1.8 g/kg limit in SIBO 09:51 Carbohydrates: 1 to 5 g/kg, peri-workout distribution and according to hunger 12:26 Blood glucose, estrobolome and resistant starch 13:16 Extreme restriction and cortisol: ketogenic diet as a short-term strategy 14:07 Glycemic index by meal, adherence and sleep 14:58 Fats: 0.8 to 1.2 g/kg, up to 10% saturated, supplemented omega-3 15:46 Physical exercise: insulin resistance and mitochondrial biogenesis 17:28 Intermittent fasting as a tool; electrostimulation does not replace training 18:20 Sleep, fatigue and a functional evening snack 19:59 New paradigm: producing energy efficiently, aesthetics as a consequence21min
• Gluten in Lipedema: HLA-DQ2/DQ8, Non-Celiac Sensitivity, and the Inflammatory TriggerDr. Alexandre Amato proposes a shift in perspective: lipedema is the smoke, not the fire. It is the body's response to inflammation, like a callus, and the central question is 'what is inflaming you?'. Drawing on his daughter's personal story (OCD that disappeared within one week without gluten) and his family's genetic sequencing, he presents non-celiac gluten sensitivity and the HLA-DQ2 (2.2 and 2.5) and HLA-DQ8 genes, usually ordered to rule out celiac disease, but which he uses to identify the inflammatory trigger. He shares data from his study: DQ2 in 47% of patients with lipedema versus 41% in the general population, DQ8 in 22% versus 11%, and both alleles nearly eight times more frequent. He explains why DQ8 shows up as 'low risk' on panels, how to order the test, the role of zonulin and secondary leaky gut, why the ketogenic diet works partly because it eliminates gluten, and why removal must be absolute (cross-contamination, processed foods, chewing gum, lipstick). The lesson includes clinical cases with photos, the relationship with fertility and pregnancy, a discussion of peripheral versus visceral fat, surgery and weight regain, myofascial release and pneumatic compression, and an overview of the Ehlers-Danlos, POTS, and mast cell activation syndrome triad, along with histamine intolerance. Chapters 00:00 Lipedema as a Response to Inflammation: The Callus Metaphor 01:40 Non-Celiac Gluten Sensitivity and the Gray Zone 02:28 HLA-DQ2 (2.2 and 2.5) and HLA-DQ8: The Test Used in Reverse 04:08 His Daughter's Story: OCD, Gluten, and Encephalitis 08:13 DQ8 and Extra-Intestinal Inflammation; Why 'I Envy Lipedema' 10:44 Prevalence: 40 to 45% in the General Population, 61% in Lipedema 12:25 Cross-Contamination: Tapioca and Lipstick 14:53 Chameleon Disease: 90% Improve After Removing Gluten 17:18 Obesity and Extreme Thinness with the Same Gene; The Book 'O Código da Inflamação' 18:06 How to Order: HLA-DQ2.2, DQ2.5, and DQ8; Nutrigenetic Panel 20:36 Discussion: Peripheral Versus Visceral Fat and the Lancet Consensus 23:46 Active Lipedema Versus Residual Fibrosis 25:22 HLA as a Genetic Antivirus; Why Symptoms Seem to Worsen After Cutting Gluten to Zero 28:40 Placing the Blame Where It Belongs: The Pizza and the Wine 31:05 Common Mistake: Reducing Without Eliminating (Processed Foods and Chewing Gum) 31:54 Carrying Both Alleles: Nearly Eight Times More Frequent in Lipedema 35:06 The Case of the Psychiatrist Colleague 37:31 Assessment with QuASiL and the Lipedema Foundation Grant 38:20 Zonulin, Tight Junctions, and Secondary Leaky Gut 39:42 The Ketogenic Diet Also Works Because It Eliminates Gluten 40:50 Therapeutic Trial: One Month at Absolute Zero Gluten 42:32 Why Nobody Studies This: Selection Bias 47:15 Patient Testimonial 48:56 Clinical Case: Ketogenic Diet, Surgery, Pregnancies, and Return with Fibrosis 52:11 Pregnancy, Fertility, and HLA 52:57 Cases: 50 kg in 9 Months; Ehlers-Danlos and Triathlon 55:22 Discussion: Myofascial Release, Pneumatic Compression, and Microtrauma 56:57 The Ehlers-Danlos, POTS, and Mast Cell Activation Syndrome Triad 58:31 Histamine Intolerance and Diamine Oxidase 1:00:55 Case: 32 kg Lost and the Change in Skin Color 1:01:45 Core Message: Get the HLA Test and Truly Eliminate Gluten 1:02:36 Elephantiasis Versus Lipedema; The Tip: Eat Healthy 1:04:10 Gluten-Free Sweets and Contamination in Restaurants 1:05:45 Closing Remarks1h 6min
• Nutrition Under GLP-1 Analogs: Meal Plan, Muscle Mass, and Preventing Weight RegainDanilo Dib closes the workshop with the most current topic in clinical practice: nutrition for patients using tirzepatide (Mounjaro) and other GLP-1 analogs. He shows why energy expenditure formulas overestimate and become useless under the medication, why 'protein only' leads to weight regain, and why intake capacity drops by 70 to 80%, especially with rapid dose escalation. He argues that the nutritionist should know the dosages and dose splitting (compounded, 1.25 mg) and talk with the physician, and that the patient should eat as much as possible within the deficit range. He debunks the myth of drug-induced muscle loss (the 25% loss is the same as with restrictive diets and bariatric surgery when there are no habits in place), discusses the lean patient with low insulin, forced fasting, and the meal plan of maximum nutrient density: whey, blueberries, fish and white meat, shakes with psyllium, and the 'hidden gems' (cocoa, oregano, functional flours, cinnamon). He presents carbohydrate periodization as an alternative to increasing the dose, the 'start low, go slow' rule, gut health under GLP-1, and concludes: weight is secondary, the metric is body composition and signs and symptoms, and the drug is a compass, not a crutch. Chapters 00:00 The challenge of the meal plan under tirzepatide: the formulas overestimate 01:38 The 'protein only' mistake and the habit that remains after the medication 02:28 Intake capacity reduced by 70 to 80%; dose escalation 04:55 The nutritionist needs to know the dosages; compounded and split-dose tirzepatide 06:31 Eating as much as possible within the deficit range 08:04 The typical eating routine that inflames; habits before the medication 09:43 Reducing quantity does not change habit: pizza from four slices to one 10:31 Muscle mass loss: what is expected and what is excessive 12:58 The 25% muscle loss is not tirzepatide's fault 14:30 Discussion: low insulin and anabolic profile in the lean patient 15:19 Indications: diabetes and obesity; no direct evidence in lipedema 16:57 Forced fasting, lipolysis, and the case of 18 hours without eating 18:38 Maximum nutrient density: whey, blueberries, fish, and white meat 20:17 Discussion: how to adjust calories throughout treatment 22:38 1,400 kcal under tirzepatide does not exist: programmed malnutrition 24:17 Carbohydrate periodization before increasing the dose 26:41 Package insert versus compounded; the 10 mg pen 28:31 Discussion: the physician-nutritionist partnership 30:06 The foundation before the icing: liposuction, bariatric surgery, or medication 31:42 The physician determines the dose: start low, go slow 32:29 Afternoon snack and hidden gems: cocoa, oregano, functional flours, and cinnamon 35:46 Gut health under GLP-1: psyllium, yogurt, and probiotics 38:15 Conclusions: weight is secondary; weight regain in 75% 40:39 The drug as a compass, not a crutch; closing remarks42min