Emma lost 20st by dieting. So should the NHS pay to remove the unsightly saggy skin left behind?
LORETTA COX had been battling with weight issues for years. So when she lost 9st over two years, following a gastric bypass operation, she was delighted. At more than 20st and only 5ft 3in, she had been morbidly obese, with a body mass index (BMI) of almost 50, putting her at a greater risk of cancer, diabetes, heart attack and stroke.
But today, Loretta is horrified with the results and deeply regrets having undergone the surgery.
Following the operation in 2009 and the dramatic weight loss, the 56-year-old has been left with huge folds of saggy excess skin on her abdomen and breasts that have made her practically a recluse. ‘It’s ruining my life,’ she says. She suffers from recurrent skin infections (though she had these occasionally when she was obese, it is far worse now as the folds are more pronounced), which require treatment with antibiotic creams and tablets.
‘I don’t want to get undressed or be naked and it’s ruining my relationship with my husband, William,’ says Loretta, who lives in Yarnton, near Oxford.
The skin droops over the top of her thighs: ‘If I want to sit down, I have to lift it up’. She wears size 18-20 clothes because of it; without the skin, Loretta estimates she’d be a size 14-16. ‘I wish I’d never had the operation,’ she says.
Weight-loss surgery on the NHS can be offered to those who have a BMI of 40 who also have a related health condition, such as diabetes. Those with a BMI of 50 and above are automatically eligible for surgery.
Loretta was referred for surgery after repeatedly failing to lose weight on a series of diet and exercise programmes.
Weight-loss operations, such as a gastric bypass, are also called bariatric surgery. They work by restricting the amount of nutrients that can be digested and absorbed by the intestine as well as reducing hunger.
AGASTRIC bypass reduces the size of the stomach dramatically to a satsumasized pouch, as well as ‘replumbing’ the gut to bypass a large section of the bowel so food is digested sooner.
This reduces the amount of nutrients that can be absorbed and changes the action of gut hormones so patients feel full sooner.
Excess skin is a common result of bariatric surgery and is impossible to prevent because of the rapidity of the weight loss.
When an obese person loses substantial amounts of weight, their skin does not return to its previous size because of the loss of elasticity as a result of years of being stretched.
‘It’s like a balloon deflating — it never returns to the size it was,’ says Titus Adams, a consultant plastic surgeon at the Oxford University Hospitals NHS trust.
Patients are typically left with excess skin hanging in a so-called ‘apron’ from their abdomen.
Other common problems are folds of skin on thighs that can cause chafing and prevent people from exercising, and excess skin hanging down from their buttocks and arms.
This excess skin can be removed with surgery — but it’s costly. While bariatric surgery is funded nationally, decisions over funding for excess skin removal are left to local health authorities (clinical commissioning groups, or CCGs) to decide.
In common with many others, Loretta’s CCG refuses to pay for surgery to remove her excess skin, which it classes as a ‘ cosmetic’ procedure. This is despite the fact that patients are meant to be given the surgery under NHS guidelines.
Loretta, a former cleaner, is unemployed. There is no way that she and her husband could afford an estimated £15,000 to have the skin removal operations done privately. Her experience is far from unique. An increasing number of patients are being left in ‘a cruel limbo’, according to consultant plastic surgeon Mark Soldin, of St George’s Hospital, Tooting, SouthWest London.
‘We are only half-treating these patients,’ he says.
‘They are left living in molten bodies. The hanging apron not only gets in the way of exercise, but also makes it difficult even to walk and to find clothes to fit.’
Fungal infections are also common, as sweat becomes trapped in the skin folds, and it can be difficult to keep the skin clean when going to the lavatory.
Unsurprisingly, many such patients suffer from depression and are unable to work or even leave the house.
A recent report Mr Soldin wrote on excess skin surgery found more than 92 per cent of CCGs are ignoring national commissioning guidelines introduced in 2014 that specifically recommend skin removal surgery for any obese patients who have lost significant amounts of weight.
Under the guidelines, patients who have shed 50 per cent of their excess body weight, who now have a BMI of 30 or below, have maintained a stable weight for at least 12 months and can demonstrate that excess skin is significantly preventing them from living a normal life, should be offered skin removal surgery on the NHS. Around 4,500 bariatric procedures are performed each year on the NHS and privately — around 70 per cent of these patients will need skin contouring surgery, says Mr Soldin, though only a small fraction will receive it.
It’s not only those who have lost weight following surgery who suffer from the lack of funding for body contouring operations.
It also affects those who have lost substantial weight under their own steam, without costing the NHS any money at all, as 36-year- old Emma Sealey discovered.
ONLY 5 ft 2in and, at her heaviest, weighing 28 st, she had a BMI of 73.2 — qualifying her automatically for weight-loss surgery.
But she was determined to do it by herself.
‘ I didn’t think it was fair for the taxpayer to have to help me out of the mess I’d got myself into,’ she says.
Having struggled with learning difficulties and then leaving school without a job, Emma, who lives in Redditch, Worcestershire, had taken to comfort eating to dull her feelings of loneliness and inadequacy. She eventually visited her doctor about her weight.
Seeing the reading on the scales shocked her so much that she embarked on the Cambridge Weight Plan, which involves shakes and meal replacements.
Emma transformed herself, losing nearly 20 st in 19 months, going from a size 32 to a size 8-10.
She has maintained her weight for more than three years and is hoping to train to become a weightloss consultant.
‘Now I feel fantastic and I’m full of energy. But I have lots of excess skin that I didn’t expect,’ she says.
‘The apron on my stomach is the worst — it reaches to the top of my thighs and I am very self-conscious. I don’t like my partner to see me without any clothes.
‘I also get infections and rashes in the folds. The weight from my breasts gives me a pain under my armpits and the excess skin on my inner thighs chafes.’
She has to wear shapewear tights and control underwear all the time.
Unable to afford the necessary £20,000 for procedures to remove the excess skin, Emma and her 45year-old fiancé, Brian, an IT worker, turned to their local CCG — only to be turned down twice.
Patients apply via their GP for funding. ‘It feels like a slap in the face,’ she says.
The couple are trying — slowly — to raise money for the operations through family and friends via a Facebook page, but see this as a long-term dream.
Experts argue the lack of funding for patients such as Loretta and Emma is short-sighted.
‘Quite apart from the human cost, in terms of the misery these patients live in, there are clear cost benefits of body contouring surgery in terms of reducing the cost of treating depression and in unemployment benefits,’ says Mr Soldin.
Moreover, some patients can fall back into bad eating habits because they feel they have no incentive to keep their weight down.
The British Association of Aesthetic Plastic Surgeons calculates the cost to the health service of not following existing free skin removal guidelines could be as high as £53 million a year.
Prejudice against obese people is partly to blame for the failure to treat these patients, says Pratik Sufi, a consultant bariatric surgeon at the Whittington Hospital in London and the Spire Bushey Hospital, near Watford.
‘ The NHS will treat without question others who could be said to have contributed to their health problems by their lifestyle choices,’ he says.
‘ If I were to twist my ankle because I fell down when I was drunk, the NHS would treat me. But obese patients don’t get the full treatment that they need.’