Dr Caroline Whymark

Dr Caroline Whymark is a Consultant Anaesthetist working in the NHS. She specialises in Obstetric Anaesthesia and has a particular interest in the management of obese patients during pregnancy and childbirth as well as when presenting for anaesthesia and surgery, of which a small proportion is bariatric.

Dr Whymark qualified from Glasgow University in 1995. After junior posts in Accident and Emergency, she began training in Anaesthesia in East Anglia and Trent, before returning to the West of Scotland. She took up her current Consultant post in 2004.

Dr Whymark also provides anti wrinkle treatments and writes articles about hospital life for several medical publications.

 

Hello My name is Dr Caroline Whymark

My articles are on obesity, health and the health profession, with a mixture of facts, myths, opinion and advice, as well as down to earth, realistic suggestions and motivation. Motivation not just specifically to lose weight but motivation to take control and responsibility for your body and to care for it as best you can. By explaining, in clear terms, some of the basic mechanisms at work in the body I hope to motivate you to assess your priorities and options and make informed choices to achieve your aims, whatever they may be. What qualifies me to do this? I have both knowledge of and an interest in obesity from a professional and personal point of view. Professionally I work as a Consultant Anaesthetist in the NHS and specialise in obstetric anaesthesia. I deal with pain relief (analgesia) requests on the labour ward and provide anaesthesia in the operating theatre for caesarian sections, repair of tears and so on. In the rest of my time I provide general anaesthetics for a wide range of surgical procedures. Although bariatric surgery grabs the headlines, the majority of obese patients present for routine surgery: gall bladder removal, hernia repair, knee operations and gynaecological procedures and I have extensive first hand experience of the issues here. On a personal note, I have been very overweight and have great empathy with obese patients. I know how hard it is to lose each and every pound and how taking your eye off the ball for even a moment sends you heading in the wrong direction.  Every pound, every day is a battle. It is not easy. If it was easy, this site would not exist for there would be no need. Remember, nothing worthwhile is easy and if something is to change, something has to change.

What is a healthy BMI for an adult?

Between 18.5-24.9 and over 30 is considered obese but research has shown some ethnic groups should try and maintain a lower BMI to reduce health risks such as type 2 diabetes.

Asians are recommended to maintain a BMI of 23 or below & although research is still underway black people and other minority groups are also advised to maintain a BMI below 25 to reduce their risk of type 2 diabetes.

Another indication of a weight issue is the size of your waist .Health risks can increase of your waist is more than 94cm (37 inches) if you're a man , more than 80cm (31.5 inches) if you're a woman

(source NHS website)
 

 

Bariatric Surgery

 

Bariatric surgery is the collective name given to all types of surgery for obesity. It ranges from the irreversible gastric bypass, sleeves and stapling procedures, which are most invasive, through to gastric band insertion which is less invasive and can be removed to return the stomach to its previous size. The principle of all procedures is the same: to reduce the capacity of the stomach. This in turn means less food can be consumed and that less of what is consumed can be absorbed. The results are weight loss superior to all other treatments, and a reduction in the complications occurring as a result of obesity.

This highlights an important point: the reason for doing bariatric surgery is not for reasons of vanity or purely wanting to be slimmer. It is an attempt to reduce or halt the explosion of chronic health problems related to obesity which continue to grow and burden the NHS financially and literally. The cost of treating diabetes and its complications account for a whopping 10% of the total NHS budget. £286 per second, and cause a significant amount of individual morbidity including ischaemic heart disease (angina and heart attacks), blindness, renal (kidney) failure and vascular insufficiency in the lower limbs causing ulceration or loss of limb or part thereof.

The criteria for bariatric surgery is morbid obesity. Until recently this meant a BMI >40 (or >35 with associated chronic health problems).
The benefits derived from such surgery are confirmed in several papers published in 2014 and are impressive. Weight loss is significant and sustained during the two year follow up period. The progression to type 2 diabetes was halted in all patients treated and was reversed in some already affected.  Following these publications National Institute for health and Care Excellence (NICE) reviewed its guidelines for doctors. The latest guideline  recommends bariatric surgery be offered to everyone with a BMI >35 and recent onset of type 2 diabetes, (recent being in the preceding 10 years,) and should be considered for those with a BMI in the range 30-34.9.

This sounds like good news and for those people who are morbidly obese at present it may well be good news. Bariatric surgery has become much more prevalent. In the last 20 years the amount of bariatric surgery carried out has increased by a factor of 20 and by 2011, over 340,768 procedures had been carried out worldwide. One third of these (100 000) were carried out in the USA and Canada, while the UK, surprisingly, was near the bottom of the league table having carried out 10 000 procedures (one tenth of the total).
Along with this increase there has been concomitant improvements in safety. Experience has increased and wider use is made of laparoscopic, telescope assisted surgery to avoid large abdominal incisions and expedite post operative recovery.

The surgery, and anaesthesia are challenging but very safe. The risk of death from any cause, during anaesthesia and bariatric surgery is less than 3 per 1000 (0.3%). This is very low especially when compared to the similar risk during cardiac bypass surgery of 3 to 5 per 100, (3-5%), a factor of 10 higher.
The risk of complications arising in the 6 months following bariatric surgery is higher however, being between 4 and 25%. These complications include wound infection, venous thrombosis (blood clots), chronic pain at the operation site, breakdown of operation site, and chest infection. These are serious events and significantly prolong the recovery period. However, surgery remains the most effective means of achieving the degree of weight loss and changes required in this population.

Although surgical treatment is now recommended more widely in the UK, there is not the infrastructure nor enough specially trained personnel to deliver this ideal to all who may want it.

I assume, perhaps wrongly, that for morbidly obese individuals, bariatric surgery is seen as the holy grail. If only they could have the operation and lose weight, they would be fine. And they may well be right. Patients typically continue to lose weight over the 2 year follow up period (the longest to date) but they also develop other problems, both physical and mental,some anticipated and others which surprise them. Gastric symptoms including reflux and diarrhoea, an inability to socialise and loss of enjoyment from food, some feel vulnerable as their weight drops and others find their partners resentful of their new confidence. Psychologically many suffer having lost their coping mechanism for their daily stresses and problems and a significant minority when asked post-operatively, say they wish they had not had the surgery and had tried harder to manage their weight through a change in diet and lifestyle.

So before you make the trip to your GP asking to be referred to your nearest surgeon, be very careful what you wish for and be sure to consider what you may be trading your current problems in for.

Next time I will talk about the options for weight management before resorting to surgery.

For more general information visit our surgery pages

Anyone contemplating bariatric surgery, particularly in the private sector, should visit more than one surgeon to hear their opinions as to what is best for each individual. Your GP may be able to recommend a surgeon and you should ask the surgeon for testimonials from existing patients. You should ask what follow up care and advice is included and for the length of time this continues. You should ensure the surgeon is registered on the Specialist Register held by the General Medical Council (GMC), that they are registered with the Royal College of Surgeons and the British Association of Aesthetic Practitioners (BAAPs). Each of these associations has a web page where members of the public can check a doctor’s registration. You should ask the surgeon what his personal complication rate is and what you should expect immediately following the surgery.
Above all, you should take all the advice you can and then go away and take as long as you need to consider whether to proceed or not. Do not be pressurised into the operation and don’t agree to the operation in the heat of the moment at your first visit. Good luck.

 

A Matter of Perspective

 

A sure fire way to make yourself look slim and attractive? Have friends who are fatter and less attractive than you are. An old joke but, as usual, based on some truth.

We can perceive ourselves to be slim, or ‘okay’ if we are no different to those around us. But what does this mean as the population as a whole continues to grow larger?  %%% of The population are now overweight or obese and %%%morbidly obese. The average ladies’ dress size is now a size 16 and this is before we take vanity sizing into account, where every size is actually larger than it was previously. This lulls us into a false sense of security, reassuring us that our size has not changed when in fact it may have risen considerably.

Our perception of ‘normal’ has changed. We regard as normal that which we see around us and as I see in clinical practice, many patients are shocked to be informed they fall into the obese category when I put there height and weight into my little round plastic BMI wheel. They genuinely do not consider themselves to be overweight at all, and telling me they have always been their current size and that everyone in their family is too.

At the same time we are continually bombarded with images of increasingly thin celebrities. They are not normal either: many have a body mass index (BMI) below the normal range of 19-25. (Use the tool at the bottom of the page to calculate your BMI.)

So how to tell if you are within a normal range or an obese category when the signs around us are so conflicting?

Well here is the good news. The diagram below shows a series of images with increasingly high weights and BMI. This was used in a study which confirmed that within a population with a high level of obesity, individuals report their perception of ‘normal’ size to be significantly higher than is correct in terms of BMI. It also confirmed that we each tend to over estimate our own size and under estimate the sizes of others. In others words, we have a negative body image and look better than we think!

Look at the series of images and decide which one represents your body most closely. Next, decide which image shows your ideal size, that you aspire to attain.

You may be surprised to learn that numbers 2,3 and 4 are normal (BMI 19-25) and number 7 is obese with the equivalent BMI of >30.

There are two reasons this is important. The first is that it is possible to follow a reducing, healthy eating plan closely yet not lose weight over a period of time. Although this is very disheartening, it may be that your measurements have changed. Measure yourself today. You do not need to tell anyone the numbers. Monitor these measurements every six to eight weeks and note the changes. Particularly if exercising, your measurements may reduce ahead of any weight loss; your size will become smaller as it changes gradually. Losing inches but not pounds is often referred to as a NSV, or non-scale victory.

The second reason this scale is important is to establish where you are aiming. What are you trying to achieve? A weight loss or a smaller clothes size? To be able to able to play with children or grandchildren? Is your goal realistic? A BMI of 25 is not possible, nor realistic for many, particularly as we age but a change, any change is worthwhile. Changing from shape seven to six, or from six to five is entirely realistic and any weight loss at all brings significant health benefits very quickly. Losing 5% of body weight, the equivalent of a 20 stone person losing 1 stone, may prevent a type 2 diabetic from requiring insulin or may avoid the need for medication to treat high blood pressure. (Check with your own doctor before altering any medication.)

Goals must be SMART. Specific, Measurable, Achievable, Realistic and Time based. Rather than vowing to ‘lose weight’ or ‘exercise more’, try to pin yourself down to specifics. For example, aim to lose five pounds before Christmas.
All long and difficult journeys start with a small, single, step.

 

The Magic Pill

Everyone can walk. No matter what your size, no matter what speed you start at, you will quickly see improvements. Try walking from your home (or work at lunchtime) for 15 minutes, then turn back. Try to get back to the start in less than 15 minutes. Try to walk further the next time within the 15 minutes, and so on and the distance you can achieve will quickly improve. For reasons of time you could break it down into two 15 minute sessions, walking out for only 7.5 minutes before turning back.

Could you do that? Could you walk for 15 minutes twice a day? I know I could. I could park in the spot furthest away from the hospital entrance rather than the nearest, likewise at the supermarket and I could leave 15 minutes early to meet my children from the school bus. If I had a dog it would be even easier. (I could perhaps borrow the neighbour’s dog!)

Just try it. Take it as you would take a medicine: walk once or twice a day, and as required in between. It may not work overnight, but it will work.

 

 

Pregnancy and Obesity

 

We are all aware that there are health problems associated with obesity. As the prevalence of obesity in society increases and individuals become obese earlier in life, obesity during pregnancy is becoming more common. Body mass index (BMI) is calculated at the first hospital visit and it is becoming usual to see BMIs of 35-45. The largest lady I have anaesthetised for caesarean section had a BMI of 62 and it presented a challenge on many levels.

Does it matter? It is usual to gain between one and three stones when pregnant, so does having a few more to begin with make any difference? The answer of course is yes, it does, and not in a beneficial way.

In order to understand why obesity increases the risks and complications associated with pregnancy it is necessary to think about what fat (or adipose tissue, to give it its proper name) is and how it affects the body in the non pregnant state.

Excess adipose tissue causes problems that can be considered under two broad headings: the physical space that the mass occupies, and the underlying metabolic processes required to sustain its existence. The former is well known to most but much less is known about the latter.

Fat tissue is living tissue and therefore needs a blood supply to deliver oxygen and remove carbon dioxide and other waste products from its cells. As fat is laid down, new blood vessels develop and proliferate, providing fat with a capillary network.

With a larger system of blood vessels to service, the heart must work harder to pump blood around the whole body quickly enough to provide oxygen to all tissues. The oxygen in the blood comes from the air we breathe With more tissue to be supplied, more oxygen is required. The blood cannot carry very much more oxygen so the additional requirements are met by increasing the rate of breathing and circulating it faster. This means the heart and lungs are working much harder, even at rest. To cope with this demand, the heart muscle grows thicker and blood vessels lose their elasticity, leading to raised blood pressure in the long term. These organs are using a proportion of their reserve continually, day to day, meaning there is less available when it is really needed: during illness and exercise or pregnancy and delivery. When demand for oxygen exceeds the supply the heart and lungs can deliver, an oxygen debt builds up in all tissues which, if left uncorrected, progresses to death of oxygen starved cells. This is the mechanism of angina, heart attacks and strokes. The brain and the heart are most susceptible to damage because they are vital organs and require more oxygen than other organs and tissues to function normally.

Adipose, or fat tissue is non-vital and requires very little oxygen to exist in contrast with the heart and the pregnant womb (or uterus) where there is rapid, active and sustained growth of the fetus over a 40 week period. The increase in maternal weight reflects the growing fetus and placenta, increased maternal fat stores for feeding, and a large increase in blood volume. The heart and lungs work around 20% harder in pregnancy to deliver oxygen and other nutrients to the developing baby and need to use their reserve function to achieve this. That’s why pregnant women get out of breath and become tired more easily.

With pre-existing obesity, some of the reserve is already being utilised to maintain excess fat tissue. What happens if there is not enough left in the tank to supply the fetus? To ensure its survival the fetus acts as a scavenger on all maternal supplies: its needs are met first at the expense of the mother’s. With blood preferentially being diverted to the fetus, any shortage will affect the mother’s organs, causing breathlessness, kidney damage and heart problems as detailed earlier. Pregnancy requires physiological reserve and exposes any lack of ability to provide this. Pre-existing obesity makes this situation more likely to occur, to occur earlier, and last longer in the pregnancy. The culmination of pregnancy in delivery of the fetus is a strenuous process: labour is well named and is physically as well as psychologically demanding.

The physical mass of excessive fat has direct effects on labour, delivery and the associated risks of both. Larger calves and thighs increase the risk of venous thrombosis, clots which form in the veins. This is made worse with immobility and the mass of the pregnancy in the abdomen, compressing larger veins downstream and increasing the pressure within, and causing fluid to be forced out of blood vessels. Legs and ankles become swollen with this fluid and the blood is left thicker, and more coagulable.

Layers of fat tissue can obstruct the progression of the fetus down the birth canal in labour and is itself a cause of obstructed labour causing fetal distress and necessitating caesarean section. Fat cannot be stitched together and surgical wounds heal poorly, being more likely to break down and become infected, again compounded by poor blood flow and oxygen delivery to the overlying stretched skin. Increased fat tissue increases the risks of pre-eclampsia (dangerously high blood pressure, headache, visual upset, protein leakage and swelling) and gestational diabetes.

In a nutshell, firstly obesity compounds the problems and complications of pregnancy, increasing the risk of them occurring and the severity of their effects.

Secondly, and more worrying from a health care point of view, is that there is very little we can do to reduce these risks. Once a pregnancy is established, a fetus will be delivered at the end of it. Pregnancy through to delivery cannot be postponed or cancelled.
This is different to an elective procedure, for example a knee replacement, where we may discuss the risks with the patient who may (or may not) decide against the operation or postpone it until the risks factors can be modified and minimised either through weight loss or better control of co-existing conditions.

At antenatal classes it is too late to modify the risks from obesity. In fact by the time the pregnancy is confirmed it is too late to significantly reduce body weight, the fetus needs building blocks and nutrients only available in healthy food. It cannot live off fat stores.(Under medical supervision patients can aim to maintain their weight in pregnancy without gaining, by eating a healthy balanced diet.) Educating teenagers at school does not work as they may not yet be obese and cannot imagine they will ever want to have a baby!

To minimise risks of pregnancy and promote the health of an unborn baby, the time to address obesity is before attempting to become pregnant. As well as developing healthier eating patterns before motherhood arrives it may mean you become pregnant more easily too.
Perhaps this is the incentive that you need to make changes to your relationship with food?

If you have any questions about this topic please email me at doctor@bigmatters.co.uk

 

The Band

Bariatric surgery is considered to be the last resort for many who are desperate to reduce their weight.

No matter what reason is motivating them, every person putting themselves forward for such interventions have one common belief: that life will better when they are slimmer.

The realists in the group will acknowledge that losing weight will not solve all of life’s problems and will not miraculously transform them into happy, healthy, miniature versions of their current selves but, it will be a move in the correct direction towards these goals.

So what if bariatric surgery does not deliver these expectations?

Until I met Gemma* I too, thought that life would be far superior following such surgery and associated weight loss. Gemma was larger than life in all senses of the phrase. She was vivacious, had voluminous hair, was attractively made up, and could talk for Britain. That day I was pleased I had plenty of time to listen.
It was a routine pre-operative visit for an unrelated procedure and I went through my usual questions. Any medical conditions? Any previous anaesthetics or operations?
‘I’ve had a gastric band fitted’, she said.
An empty stomach is vitally important before anaesthesia, to prevent passive regurgitation and aspiration of its contents. I was considering the relevance having a stomach the size of a walnut when she continued
 “It’s the worst thing I ever did you know” she paused for the first time during our consultation.
I looked up.
“What is, losing all that weight?”
“No,” she said, “Getting the gastric band put in.”
She had weighed over 20 stones a year ago and was now a mere 13 stones, thanks to her ‘band’ as she called it.
I was surprised by her statement. Many people are much happier having lost such a significant amount of weight. I assumed that everyone would be. Why ever not? My surprise must have shown.
“Oh, it was great at first” she said, “There was a definite high as weight started to come off. The numbers went down, my clothes became too big and the compliments were rolling in. I even persuaded my mum and my sister to go and have a band fitted too. But then it changed”.
“In what way?” I asked, genuinely bewildered and interested to hear.
“Well, I started to become normal.” This was clearly not a positive development for her.
“No-one stares at me in the swimming pool any more, I can now shop in high street rather than from out-sized catalogues, I can talk about diets like everyone else, yet I’m miserable”
“Oh, in what way?”                                                       
“Every way!” she exclaimed and launched into the difficulties she now had.
“I LOVE food and I can’t eat it; the band has left me with no choices. I can’t decide to have a day off the diet or decide to allow myself one chocolate bar; I physically cannot accommodate the food anymore. Socialising and even just going out is difficult. I can’t eat from a buffet, I can’t enjoy a canapé,  and I can’t grab a quick sandwich if I’m out shopping at lunch time. I’m restricted to smooth, sloppy, baby like food that will fit through the band. It’s almost impossible to go out for dinner. If I see another bowl of carrot and coriander soup I will be tempted to drown myself in it! I used to be the centre of attention for all sorts of reasons but now I just blend in. I look the same as everyone else; a bit overweight and usually wearing the same party top as at least two other people in the room. I have become completely unremarkable.”
I was stunned by her revelations. I believed a gastric band to be an easy solution to a difficult problem. I believed losing weight would solve more problems than it would create. It seems in life as well as in medicine, things are never that straight forward.
It is easy to forget there are individuals behind the population guidelines. A Body Mass Index of 25 may not be the Holy Grail for the entire overweight population. Morbid obesity undoubtedly carries many great health risks, but so does chronic, deep unhappiness.
There are very few obese people whom I believe to be truly happy with their size, but I think Gemma is one of them.
*name has been changed to protect identity

 

 

 

 

 

 

 

 

 

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