Obesity: The Post Mortem

Obesity is an epidemic happening right here in the UK, right now.

Honestly, the first thing I'll say is I'm a big girl.

How my friends would describe me would be large - fat, probably.

I don't like to use the word fat but, at the end of the day,

that is what I have inside me - I have a large amount of extra fat.

We all know what fat looks like on the outside.

I think of cellulite, rolls...

..big thighs, big arms.

If you're Kim Kardashian you can have a really fat arse.

I... I've got a fat stomach.

She's got a fat arse.

But what if we could see what fat looks like from the inside?

Do we have any idea of the damage obesity is doing under our skin?

When you say to somebody, "Oh, well, it's affecting your health,

you know, show me. I can't see inside.

I can't see what's happening inside me.

BBC Three has secured the first televised access

to a full postmortem

on an obese person whose body was donated to medical science.

This summer, our pathology team assemble to reveal, from the inside,

the dangers of us all getting too fat.

Postmortems are tightly controlled,

and access to them is strictly limited

to protect the privacy and dignity of the deceased.

Filming is not usually allowed.

But for this postmortem, we have been allowed in,

to help understand a problem that costs the nation billions

and ruins so many lives - obesity.

Carla Valentine and Dr Mike Osborn

are the specialist team responsible for

carrying out the postmortem.

Carla is an anatomical pathology technologist,

and technical curator of the pathology museum

at London's Queen Mary University.

For this postmortem, I'll be carrying out the evisceration,

which means removing all of the organs.

Being part of a filmed postmortem is a very unique opportunity.

Death terrifies some people,

but what it also does is it eventually gives you

a real sense of the fragility of life.

The topic of obesity is a huge problem,

and it's something that I get to see quite a lot,

but it's not something that I get to study in depth.

Mike is a consultant pathologist,

and fellow of the Royal College of Pathologists.

He's been working with death and disease for over 20 years.

Obesity is very much there, it's seen, but I think it's very,

very poorly understood.

It seemed that making this film would be a way of exploring that,

and allowing a broader public to learn about

the problems that are associated with obesity.

Carla and Mike have performed thousands of postmortems,

but always behind closed doors.

Today, we'll witness what really happens in an autopsy,

and discover what the body of our donor can tell us about

the creeping effects of obesity over time.

We don't know this woman's name, but we do know a few details about her.

She was in her early '60s...

..five foot five...

..almost 17st...

..and, just like a quarter of people in the UK,

clinically obese.

But where did she come from, and how did she end up here,

on a postmortem table in London?

Long Beach, on the west coast of the United States.

Glamorous, sunny, carefree California.

But, away from the beach,

on an anonymous industrial estate on the outskirts of the city,

is where our donor began her journey to the postmortem table.

This is a place where people who donate their body

to essential medical science are brought when they die.

Up to 20 donated bodies -

or cadavers - a day come through these doors,

destined for thousands of medical research projects

all over the world.

My name is Randall Delgato. I'm 29.

My main role, now, would be in charge of distribution.

Some days, you know, we have an order for cadavers

heading into Lebanon, and so then, you know,

we have to start checking on them. How are they looking? Are they firm?

Is there mould growing on them?

You've got to be a certain breed of person to be able to do this,

you know? I mean, at first, it was very like, "Oh..."

But, you know, eventually you get used to it.

I'm Kelsey, I'm 32, and I live in Costa Mesa, California.

We perform a procurement on each donor that comes in,

which entails us dissecting different specimens from each donor.

We get to dissect the brain, take certain parts of the brain,

and the internal organs, or taking

veins and arteries, different parts of the eye.

The job itself can still be pretty taboo.

I mean, even when I first came here, I wasn't exactly sure what they did.

I knew they recovered tissue,

but I didn't know to, like, the extreme of,

like, really recovering almost everything.

Our donor was processed here, in preparation for her final trip.

Her left arm was removed for cremation,

and its ashes returned to her family in California.

The rest of her body was frozen, placed in a body bag, boxed,

and labelled for transportation to London.

From here, she made her last car journey

through the streets of California.

She was loaded into the hold

of a plane and carried 5,000 miles from her home.

And, finally, she arrived in London.

Her body remained in a cool chamber for ten days,

to allow it to thaw completely,

before it was brought to the postmortem table.

The first stage of every postmortem,

before any cut is made to the flesh,

is an external examination of the body.

The donor's ID number is confirmed against her medical record,

which details the cause of her death - heart disease -

and that she'd only had minor surgery and drank minimal alcohol.

But what will her body go on to reveal about the way that she died?

This lady died of heart disease,

which is one of the things that is associated with obesity.

And, interestingly, already in this lady

we've got signs of heart failure, because if I press here,

-particularly, on this side, you can see...

-Oh, that's very evident.

The dimpling, there. And that's because you've got too much fluid,

and that's the side-effect of heart failure.

The other obvious external damage to our donor are the blisters

on her skin.

They are one of the earliest signs of her body decomposing

after death,

and they're particularly noticeable on larger bodies.

But they're not what Mike and Carla are focusing on.

The most important thing about this lady is that the obesity that she's

got is centred on her abdomen.

So this lady's carrying a lot of weight around her tummy.

That's associated with more of the complications

than if somebody weighs the same but they carry their weight

around the bottom and around the thighs.

So that's less associated with complications.

That's more associated with complications.

So we can see the distribution of the fat from the external exam.

But once we actually get inside, we'll see more of

how that's affected the inside of her body and her

internal organs, as well.

When we open this lady, there may be other findings

that are less easy to diagnose before somebody has died,

that won't have killed her but are examples of problems that can

get worse and lead to illness and death in other people.

So we may find some of those, we may not.

To uncover if there are deadly medical truths

lying beneath the skin, Carla must first cut open the body.

The incision is a large and deep single vertical cut,

beginning at the suprasternal notch

at the base of the neck, and ending at the top of the pubis.

It's a skill that requires both great precision and intense

concentration, especially performed on someone with so much fat.

So what I can feel at the moment is an awful lot of yellow,

very sort of greasy, fatty tissue,

which...is quite a thick layer in a body this size.

Reflecting the skin, back from the ribcage, here,

and what that means is I'm just kind of loosening it

away with the muscle,

to give me a bit of room to manoeuvre within the body.

What we seem to have here is a breast implant.

This is an incidental find.

Sometimes, when we do postmortems,

it's not just about what we're expecting to find, it's incidental.

There is a very large amount of fat here,

and the reason it makes it so difficult is it actually is greasy -

it feels very much like butter.

So what I'm doing here is just trying to make sure that my...

..knife doesn't slip too much on it.

Mike, did you want to come and take a look at this?

OK. So, we can see, immediately, the thickness of fat that is here.

And even though there is a large amount on the anterior chest wall -

the front of the chest -

there's also a very large amount around the abdomen.

The abdominal fat - that is the most dangerous,

associated with the problems of obesity.

There's quite a lot of fat around the organs.

There's fat in the omentum.

It would appear that this lady's carrying much of her weight in the

abdominal fat and possibly around organs, as well.

So there's lots of changes, which I think we'll get a better view of

when we've opened the rest of the body.

Everybody knows what obesity looks like from the outside but,

unless you do a job like ours,

most people don't see what obesity looks like inside.

I've done thousands of postmortems.

It's always a fascinating procedure.

Even if it's a case where you've seen lots and lots of

similar cases in the past,

that particular case will be individual,

and you'll certainly learn from that.

We'll never know exactly why our donor became so overweight.

The reasons for obesity are multilayered and complicated -

a mixture of lifestyle and environment, biology and psychology.

But now that overweight is the new normal weight in the UK,

there is a whole new young generation

living with the consequences of obesity.

Fat! You know? "Oi, fatty", "fat bastard",

you know, whatever it might be. I mean, I remember walking past

my local pub once and someone said,

"Oh, fat bastard, how are you?"

It doesn't matter how old you are,

if you're fat, you are marginalised by society.

There's a lot of medical contributing facts

to people's weight that a lot of people don't realise,

and all they see is somebody that's big,

and they assume that they eat a lot.

Myself, you know,

I suffer from polycystic ovaries and also underactive thyroids.

So, as a child, I was always slim.

I come from a family that's quite slim, their build is quite slim.

You know, it was only when I hit puberty that I started

putting on this weight.

I was diagnosed with epilepsy,

and the first medication they put me on,

I put on a lot of weight quite quickly.

I lost a lot of self-confidence,

which I think also led to me putting on more weight.

The emotions and feelings that I associate with eating

are quite difficult, because I...

There's a part of me, because I'm recovered

from binge-eating disorder,

there's a part of me that still, if I've had a difficult day,

wants to go home and eat a lot of things in one go, which,

you know... I wouldn't enjoy them,

it would just be because that's what I have done in the past,

and that just seems to be something that I've picked up as a way

of coping, which I've now moved away from.

But that's still something that I'm conscious of,

and still occasionally want to go and do that.

Sometimes, you know, I'm not going to lie,

I do eat some of the wrong foods.

And, you know, I don't go to the gym as often as I should.

During my 20s, you know, I did, I partied a bit.

I was going out with my friends on the weekend.

You know, binge drinking

all weekend's not a good, healthy lifestyle but,

at the time, I didn't care.

Food is pretty much central to our existence.

Mum would always complain that we're always thinking about our stomachs.

I suffer from a sort of severe lack of self-discipline.

So, when I go to the supermarket,

I'll generally walk through the door and the first thing I'll see is the

things on offer - biscuits, two for one.

And then I'll see the salad.

And it's salad.

And you've got carrots and you've got hummus,

and you've got Maltesers and you've got Twirl and you've got Buttons,

and Dairy Milk this and Twix that, and it's cheaper and it's on deal -

why wouldn't I? It spirals, and it gets out of control.

It's just quite sneaky, really,

the way that it kind of creeps up on you if you sort of

take your eye off the ball.

The next stage of our postmortem is for Carla

to go deeper into the body -

beyond the surface fat - to get to the organs.

What will we discover from them about the damage that fat has done?

The organs come out in blocks,

because they all fit together in a certain way.

So, for example, with the cardio-respiratory block,

which is the heart and the lungs,

these are specifically together and above the diaphragm,

so you have a natural line there that sort of

makes them into one block or "plug".

So if I remove those and I give those to the pathologist,

he can then take a look at those organs

while I carry on with the next block.

To get to each block, Carla must first remove the sternum -

the bony armour that protects the major organs of the body.

It's not an easy job,

requiring skill perfected over years and a bit of brute force.

So I'm going to take my rib shears -

we use these specifically for this job as they can cut through bone.

And what I'm going to do is just make some very even cuts,

right through all of these bones.

You can hear the bones are snapping.

This lady isn't exactly young.

The older people get, the more calcified their bones become,

so they become very, very crunchy,

whereas younger people tend to have much more soft bones.

In order to do this job you have to be strong of stomach, to start with.

But I think that's just something that you either know or you don't.

I never would have considered doing this job if I didn't know I had

a strong stomach. I'm now removing the breastbone,

or the breast plate, the sternum, with upward strokes.

And this way, I don't damage any of the pericardium,

which is the sack that keeps the heart safe.

The first time I saw somebody doing a postmortem,

I think I was just absolutely rapt, I was fascinated.

And it's because the human body is an incredibly complex machine.

To open a human being, to see all of that absolutely perfect sort of

jigsaw of organs and perfectly placed,

it really did make me feel very awed.

When you do an autopsy on somebody who's very slim,

the organs are there and they're very evident.

It's like a game of Operation,

or like one of those anatomical models that you would use at school.

In a woman this size,

a lot of it is really hidden by this extra yellow fat.

It is making it quite difficult to see the structures -

much more difficult than it would if she was a thinner person.

Before Carla removes the heart and lungs,

Mike wants to take a look at the organs while they're still

in the body, to see if we'll discover

any early indications of trauma or damage.

You can see the heart here.

There's a large amount of fat around the heart.

-There's more here than you would see normally.

-Definitely.

-Quite considerably more.

Underneath the heart and lungs, in this area, here,

is what you call the diaphragm -

that's a big muscle that helps you breathe.

Even the diaphragm - I was going to ask - seems very fatty to me.

That's right. Even on the surface,

where the heart fat and the diaphragm are meeting,

there's more fat than usual.

And, actually, the thing you can see most is an extremely enlarged liver.

This is very, very large,

and it's got what we call "fatty liver change".

So this is a fatty liver,

and fatty liver is very much associated with obesity.

You can see there's a lot of fat around these organs,

so what would be between my hands now would be the kidneys.

Now, the kidneys always have fat around them.

I think it's important, while we're talking about the fat,

to realise fat is a normal thing.

Everybody has fat in.

However thin you are, there will be some fat, and fat has got very,

very important roles, and one of those roles is to protect things.

It's the too much fat that is the problem.

Fat is made up of cells called adipocytes, which are fat cells.

And, really, for a long, long time - until very recently -

people thought that fat was just an inert substance that just sort of

sat there and didn't really do anything.

But it's becoming increasingly understood now,

that fat is actually a very active substance.

Fat cells work almost like an endocrine organ.

People will have heard of some endocrine organs -

things like the thyroid gland is related to how much energy you have,

how cold you are, so forth.

The ovaries, the testes - so, obviously,

these hormones related to the ovary and the testes define whether you're

going to be a man or you're going to be a woman.

So those are the sorts of activities hormones have, so they're very, very powerful things.

And then it's become obvious that the adipocytes, the fat cells,

do play an endocrine-type role

and so have some very powerful effects that

were previously unknown.

Exactly how fat works and what it does is still far

from completely understood,

but the day-to-day reality of obesity can be devastating.

I wish I hadn't left it so late to try and start losing weight.

It's not good on your back. It's not good on your knees.

You know, God knows what it's doing inside.

I thought, "Right, OK, I'm 30 -

"let's start thinking about trying to have a baby."

But with the size that I am,

you know, you won't even get any help with,

sort of, IVF and things like that because it's...

You know, the answer is, "You're too big."

I've always felt insecure,

thinking that I would perhaps never ever find love because I'm fat.

Even if it's practical things such as travelling,

going to a funfair or going to a theme park

and knowing I have to sit in a seat that is tiny -

things like that, and...

There's so many things. My wedding day - preparing for that,

preparing my body for that, so how it will look in photos.

And even social media.

In fact, my whole life is surrounded by it.

I've got sleep apnoea because of my weight.

And what that means is that

when I lie down to go to sleep at night,

the extra weight on my neck and on my face

actually compresses my airways,

so that it stops me breathing properly and therefore wakes me up.

It was waking me up about every two minutes throughout the night.

So I wear a machine, and it's essentially a small air pump.

It just keeps pressured air going into my airways

through the night, so I don't wake myself up,

so that my sleep's a lot better. Very glad to have the machine.

Would have been much gladder to have not needed it at all.

When I first properly started thinking of myself

as overweight was when I started looking at wedding dresses.

It's meant to be, like, a really, really happy time,

and I just felt uncomfortable,

and just ugly and disgusting,

and I just - I didn't want to be there.

The woman said that they were going to have to order me a size 20,

and I thought it was going to be, like, a size 16,

and I was just, like, absolutely out of my mind.

I had, like, no idea I'd got that big.

It was really, really awful. I think I cried most of that night.

I was angry at myself to have got so big and not have noticed.

Like, I just felt stupid.

The next stage of the postmortem is the dissection

of the heart and lungs. For Mike to be able to do this,

Carla needs to remove the cardio-respiratory block

from the body.

I'm cutting through the diaphragm, here,

just to make sure that I've freed the lungs completely.

Free them along the spine here.

I'm going to do the exact same thing on the other side.

And then chop across the oesophagus and the trachea here,

and then all I need to do is, basically,

pull the organs towards me,

at the same time as releasing these, sort of,

white fibrous tissues that are holding the organs to the spine.

And then we'll get to a point...

..where this block - the cardio-respiratory block -

is completely free.

And then we can take this out as one block.

And we've got the heart and the lungs and the heart sack -

the pericardium.

When you initially carry out a postmortem

and you hold an organ such as the heart in your hands...

And the heart is very symbolic...

..you know? We use it in all sorts of logos.

It has a sort of power and a sort of agency

that makes you kind of stop and think.

Because it looks so mundane, but then you realise that within it

has the electrical impulses to keep a person alive.

With the cardio-respiratory block removed from a donor's body,

Mike can start his dissection of her lungs.

Will we uncover any evidence of damage linked to her obesity?

I'm going to detach the lungs from the heart.

So we'll start off with the right lung.

So, just cutting through...

..where the lung is attached.

And that's the right lung detached.

This is the left lung I'm detaching.

There.

I'm just going to make some cuts across the lung,

just to see what the surface of the lung looks like.

These lungs actually look quite healthy.

There's no tumours or masses or anything like that in these lungs.

But what there does seem to be,

and which should be evident now if I pick this lung up and squeeze it...

..is you can see the fluid dripping out of these lungs.

And this is what we call pulmonary oedema -

that's essentially heart failure fluid.

This fluid is basically water.

I know it looks red - that's because, obviously,

it's within the body and it's been mixed with blood.

This isn't... Blood is much, much thicker than that.

This is really just a watery fluid.

And this has collected because this lady's got heart failure.

This lady died from heart failure, from hypertensive heart disease.

But this lady is also obese.

She did not die from the obesity -

the obesity increased the risk factors,

and was associated with the problems that led to her death.

Fluid has built up in this lady's lungs.

Because her heart isn't working properly,

she'd have probably been short of breath and possibly had a cough.

But, also, because the fluid sits in the chest when you lie flat,

and that would have given her sensation, almost, of drowning.

When you become a doctor, one of the questions that they teach you

very early on is how many pillows do you sleep with?

And that tends not to be because they're asking

how comfortable you are at night -

it's because if somebody says, "Oh, I can't sleep in a bed, doctor.

"I have to sleep in a chair" or,

"I have to sleep with eight pillows, sitting up",

that is very indicative of heart failure.

From the startling discovery Mike has made in our donor's lungs,

we now know that she would have felt the impact of her obesity

and heart failure every single day.

Heart failure is not the same as a heart attack.

When a heart fails, it doesn't fail immediately

in this type of circumstance.

It fails over a long period of time, so the symptoms are gradual.

So this lady may have been able to walk up ten flights of stairs

three years ago, then she suddenly found she got very breathless

after five flights of stairs, then she found that she found it very,

very difficult to even walk up one flight of stairs,

or even carry her shopping. It would have been a progressive disease,

as the heart became worse and worse and worse.

Now, the final event, obviously,

when this lady's heart stopped working -

that would have been an instantaneous event and led to her death.

Now it's time for Mike to examine, in detail,

the organ that catastrophically failed in our donor.

What will we find out about how and why she might have died?

You can't really see the heart yet,

because the heart is sitting in a bag.

This is called the pericardial sac.

I'm just going to open that.

And so I can reflect that back and that's the heart there.

So the heart, now, is in my hand.

And you can see all the fat I was talking about earlier really isn't

around the heart, it's really around the pericardium.

There is a bit of fat around the heart, which is here.

This is absolutely typical and everybody's heart,

even a thin person's heart, would have this.

And I'm going to cut off the pericardial sac.

This big blood vessel here is the aorta.

This is the vessel that takes all the blood

from the heart round the body.

When I feel this heart, it feels baggy.

A heart, in someone who is very athletic -

their heart would be very tight, very firm.

It would be like, almost, picking up a piece of steak.

This is more like a bag.

What I'm going to do now is weigh this heart.

So this heart is 449g.

That's a heavy heart. This lady is, despite her weight,

this lady is actually quite a petite person.

So you would expect her heart to be perhaps 275g, something like that.

So this is very much heavier than you would expect.

And that is the sort of size heart

you would expect in someone who has got heart failure

due to high blood pressure,

which is what this lady suffered from.

The heart, basically, has to pump to keep up the pressure.

The heart gets bigger and bigger and bigger.

But there comes a point where the heart can't get any bigger,

and it basically exhausts itself.

Now that he's discovered the shocking state of our donor's heart,

Mike wants to look at it from the inside.

He cuts some slices so he can examine the ventricles -

the walls of the heart that pump the blood.

If you're a 6'8", All Black second row,

or you're, you know,

one of the professional footballers running around the pitch,

you need a lot of blood.

So the wall of the left ventricle, in a young, fit person,

is usually an inch-thick muscle all the way around.

Now, if you look at this lady, this lady's left ventricle is very,

very thin. This is eight millimetres, something like that.

That's because she developed high blood pressure to start off with -

the heart had to pump harder and harder.

In the end, what you get to is a state where the muscle can't keep

the high blood pressure up,

and it starts to get thinner and thinner and thinner.

And, basically, you go from a thick, muscular pump,

through to a paper bag that's not capable of pumping blood adequately

around the body. And we see a lot of these hearts.

We see them on a background of hypertension.

This is a common finding and becoming more common.

Hypertension is high blood pressure.

Obesity is well known to be one of the major risk factors

for high blood pressure.

So, in this lady, they were not able to control that.

That led to changes within the heart which meant the heart failed,

it couldn't work properly. And that's what this lady died from.

Obesity is a killer - not by itself,

but in the many ways that it triggers and accelerates disease.

But so much of the way that we think about fat isn't medical at all -

it's personal.

I have been fat all my life.

And it's never been a positive thing for me.

I've always associated it with something negative, to be honest.

I feel like

fat is a filter through which I'm seen,

because there are certain stereotypes that go alongside

being fat, being overweight,

that maybe people who are overweight

are lazy or not very clever.

I don't know why. I don't know where those have come from.

But I feel like I have to try extra hard to prove those things wrong.

I don't think I necessarily would associate my fat with, you know,

being invited to, you know, get-togethers with friends

or going out. But, you know, if they were going to play a game

of football or rugby, they might think twice.

Socially, in terms of relationships, it definitely has.

I mean, you go into a bar and you look like a GQ cover model,

versus me, the girl's always going to go for the GQ cover model, sadly.

Try as I might to be the funny fat guy.

You try to build this wall, this wall that, you know,

you just sort of try to ignore it. And from strangers you can,

because you think, "Well, they don't know me."

But when somebody who's supposed to love you and somebody who's supposed

to care for you and somebody who's supposed to accept you

for who you are, when they call you fat, just to hurt you,

the feeling is just horrible. It's not a nice feeling at all.

It makes you feel really low, sad, alone.

The next block of organs to be removed

are the organs of the digestive system,

called the coeliac block.

What I'm trying to do here is make sure that I've got the stomach

and the lower bowel and the liver and the spleen

all together in one block,

for Mike to take a look at, and not damage the kidneys.

But, at this point, I don't think I'm going to be able to damage them

anyway, because they are so surrounded by

such a large envelope of fat.

So we've got some faecal matter,

we've got some bile and then, obviously, a lot of blood.

The blood's mixed in with the fat, which is yellow,

so that's giving us some orangey fluids.

It's a multisensory rainbow at the moment.

Every single thing that is in each of these blocks

is incredibly important and, you know,

does amazing jobs for our body.

It's just a case of...it's not very pleasant, once they've stopped

working and they've started to decompose a little bit.

To completely free the organs, Carla needs to cut through

the fibrous membrane that holds them to the spine

at the back of the body.

So this is a huge coeliac block.

It is incredibly heavy.

The liver, as you can see, is taking up most of it.

You can just see the spleen, there, and also the stomach,

and a bit of the small bowel is attached, as well.

When I first encountered a deceased person,

I think what really struck me was just the stillness and the cold.

Because, of course, I'd never, at that point,

felt flesh that was so cold.

And it gave me a real sensation of kind of

dipping my toe into very cold water.

And then, once I'd done it, that feeling had never quite left.

It was like this other, subterranean world.

In the next stage of the postmortem,

will we find any evidence of fat damage in the organs of our donor's

digestive system?

This is the organs that include

the liver,

the spleen, the stomach and the pancreas.

Now, this is much heavier than I would expect it to be in a smaller

individual, largely because the liver is so big.

First, Mike is going to take a look at the organ that most people

associate with obesity.

This is the stomach.

Basically just like a bag that holds the food,

before the food goes through into the bowel

where it's actually digested.

And there are actually many...

of the treatments associated with obesity deal with the stomach.

And what they try to do is reduce the size of the stomach,

so that people have a feeling of being satisfied from eating

without eating so much. So there's a whole variety -

gastric bands fit around the stomach,

there's various bypass operations and so forth.

The stomach is very good at dilating.

So, if this lady had had a very large meal before she died

and had not had opportunity to digest it,

the stomach would be much more obvious.

But this is a fairly typical size stomach.

Next, Mike will dissect the liver - the organ he discovered showing

such dramatic change when he saw it in the open body.

But what will it reveal to us about the consequences of fat

building up where it shouldn't?

First thing I saw when we opened the abdomen was the size of this liver

and the fact that this liver showed marked fatty change.

I'm going to make some slices through the liver,

just so I can see what the surface, cut surface of the liver looks like.

The sponge, so I don't cut myself.

So I've made some cuts across the liver, there.

And you can see that the surface of the liver

is this sort of pinky colour.

That's very characteristic of fatty liver change.

It's very soft. It almost feels like pate in consistency.

Normal liver is quite soft, but not as soft as this.

And it has a much meatier, much redder, bloody colour - dark red.

The lightness in this is caused by the fat within the liver,

and the fat is deposited within the hepatocytes,

which are the liver cells.

This fat would obviously be pale in colour,

and liver cells themselves are dark, so the combination of the two

gives you this light, sort of, pink colour. That's a much,

much lighter colour than you'd expect a normal liver to be.

That is a classic sign of fatty liver disease,

and it's becoming a major problem,

and is one of the major reasons for liver transplant in the world.

The most common cause of fatty liver, at the moment,

is alcohol-related fatty liver.

But we know that this lady drank almost nothing,

so it's very unlikely that this change is due to

alcohol consumption.

Almost certainly an obesity-related change.

Fatty liver causes damage to the liver.

It can lead on to cirrhosis,

and it can actually lead on to cancer as well.

But even if people do not develop cancer or cirrhosis,

it can lead to liver failure.

So there's multiple ways that it can actually lead

to the death of a patient.

It didn't lead to the death of this lady,

really because her heart was itself so bad,

but this is very dramatic change within this liver.

Before the postmortem,

we could never have known how dramatically damaged

our donor's liver would be,

or that she'd be carrying a second life-threatening disease.

But excess internal fat doesn't have to be a death sentence.

The good news is the fight to beat the dangerous invisible fat

can be won.

It is a daily struggle, but the prize is big.

Now I'm trying to lose weight.

I've actually lost 3.5 stone.

I'm in a weight management clinic.

I get support through a dietician.

I get support through weekly weigh-ins.

I get support from a counsellor, you know, which is really,

really handy to help with your mental,

you know, frame of mind as well.

So what I've been doing to lose weight is cutting out the chocolate,

cutting out the biscuits, cutting out the crisps - all that stuff.

I'm not perfect. I still have the takeaways, you know?

I still have the cheeky bar of chocolate.

But, you know, I've also been exercising a lot more,

and really pushing myself to exercise, you know?

Pushing myself to get to the gym.

In terms of activity, I struggle.

I try and get in an hour of walking a day,

but I don't always manage it.

Just walking around the park

half a dozen times doesn't really do it for me, you know?

I don't like running - I have a problem with my knees.

To start jogging around a park is not only just a physically difficult

thing, but it's an emotionally difficult thing to do -

to get out there in jogging gear,

for all the world to see some, you know, parts of your body's jiggling

that you just don't want them to see, sadly.

I've had gym memberships up the wazoo.

I've done detoxes for 22 days,

just drinking lemon juice, cayenne pepper,

water and a bit of maple syrup.

It's disgusting, I can tell you.

But I have tried a lot, and I will probably end up trying more.

But I think slowly getting better and making better choices is really

where it's all about.

My motivation to now tackle my weight,

and to try and reach a healthier weight is because

I have now recovered from my binge eating disorder.

It's a shame that it had to get this bad for me to, you know,

to get to this point, but I did need to access that, sort of,

psychological help first, in my case.

You know, I've now seen the limits that being overweight has put on

my life, and I want to reverse those

and get back out there and just live life to the full.

I'm quite conscious, these days, of what I eat.

I do go to the gym.

I do what I can to lose weight,

or at least maintain it even if I can't lose it drastically.

OK.

Turn a little bit.

I am a plus size style, beauty and lifestyle blogger.

People do get inspired by those sort of things,

so I think it's quite useful for me to, kind of, you know,

get out there. It's actually helped me boost my confidence.

Perfect. Yup.

Exercise is not my best friend.

It's quite a chore for me, in a sense.

But I feel that, in life, with a lot of things, you've just got to,

you know, make the effort to do

things even that you don't necessarily love.

In January, I decided to join a running club

called Too Fat To Run.

And it was really, really scary at first.

I went out and I ran for, like, ten minutes,

which doesn't sound long, but when you haven't run

and then, suddenly, you can run for ten minutes,

you're like, "Oh, crap, I can do that. That was kind of cool."

Then I did my first 5K race.

Finishing a race feels so much better than, I don't know...

It sounds really, really cheesy,

but it feels so much better than finishing a pack of crisps.

Every race I do, I can't believe that I've finished it.

Next, Carla will remove the final group of organs,

but even in the last stages of the postmortem,

she takes nothing for granted.

People who donate their bodies to medical science really are giving

a gift. It is the gift that keeps on giving, actually, because,

as a patient, I think we all would prefer

that our doctors and our surgeons have learned

on something, you know, realistic to their job

before they're let loose on a human patient.

You know, you wouldn't really let a mechanic take care of your car

if he'd never touched an engine,

and it's very much the same thing with this.

Real bodies are very unpredictable

and very chaotic compared to anything,

you know, fake - anything like a virtual reality or a fake cadaver -

because if you look here,

what you should be able to see are the kidneys -

granted, they always have a tiny capsule of fat around them,

a bit like a sort of edamame bean, that you can pop out -

but these fatty capsules are very, very large.

So all that you can really see at this point is a kind of yellow,

glistening mess, really.

So this is, again, indicative of the fact that she has

an awful lot of extra fat around her organs.

So I'm just slicing through the fibrous tissues and the bits of

muscle that are keeping the kidneys attached to the spine.

And it's really exactly the same thing that I've been doing

with the rest of the organs,

and that is releasing them from the spine,

which is what anchors them in place.

And then I can just reflect them all the way down and pull them out.

And this is the genitourinary block.

And this is at least slightly smaller, slightly easier to manage,

cos we've only got the kidneys in this.

So much fat, still.

Mike needs to dissect the kidneys to find out just how much damage has

been caused by all that excess fat.

This is the right kidney. This is the left kidney.

This, in the middle, is the big blood vessel

that carries blood all the way down the body.

And the most important and the first thing I can see is

there's an unusual amount of fat around these kidneys.

Now, the kidneys always have fat around them.

Kidneys are not protected by bone,

which means that they can be bashed and they can be hit,

if you walk into something or something hits you,

so this fat protects them.

This lady has much, much more fat than I would expect.

What I'm going to do first is just cut through this fat,

which is called the perirenal fat.

And you can see quite clearly how much fat there really is.

In a thin person,

this would probably be...

..half or a third as thick as I can see here.

This is bad news for this lady.

It means that she is more likely to have the complications of obesity,

because of the way she's carrying the fat.

This pale area here is the kidney.

I'm just going to cut into the kidney.

So the kidney's got a thick capsule around it.

Now there's a small amount of fat in the middle of the kidney.

That's completely normal.

That's where... Basically, the kidney is responsible for

filtering your blood and for making the urine.

That urine has to go somewhere, so your kidney's got a funnel

that collects all the urine from all the bits of the kidney,

takes it down through your ureter into the bladder and then,

when you want to go to the loo, it goes out.

So this bit of fat sits around that funnel area, and is quite normal.

I'm going to take the thick capsule off of the kidney surface,

to see what the surface of the kidney looks like.

The surface of the kidney, ideally, should be very, very smooth.

This kidney has got some scarring on the surface.

There's areas of indentation and pock marking.

There is clear damage to this kidney which would be associated with high

blood pressure, and we know this lady had high blood pressure,

which is what led to the changes

within her heart and which led to her death.

The visible scarring and pock marking we've discovered

on our donor's kidneys are the last of the revelations she will yield,

before Carla completes the postmortem

and closes the body for ever.

When Mike's finished his examination,

I then begin the reconstruction.

And, in a way, that's one of the most important parts

of the postmortem.

What I do is, I place all of the organs into a special viscera bag,

which will contain all of the elements that we've removed

in the different blocks, and I place that into the body cavity.

And then I use very heavy postmortem twine to stitch, as neatly as I can,

right along the incision that I made.

We describe this as a baseball stitch -

it does look very much like a zig-zaggy stitch.

Each postmortem is unique, and everything they reveal valuable.

This donor's gift was an opportunity for Mike and Carla to unveil the

shocking truths hidden inside one body,

irreversibly damaged by too much fat.

The evisceration occurred,

and it wasn't as easy to do as it would be with

a slightly smaller patient.

It takes a lot more strength to cut through this yellow adipose tissue,

which kind of blooms out of the abdomen in this, you know,

practically neon yellow.

And it looks very much like butter, and it has a greasy feel.

And it makes you suddenly very aware of the fat in your own body.

Well, it made me aware of the fat in my own body,

and the effect that that might have on my organs,

the strain it might put on my heart, the way it may affect my liver.

I think that doing a postmortem such as this

is a really fantastic way for people

to consider their own health and their own mortality.

We never really know what we're going to find

when we examine the patient.

The first thing I noticed when the body had been opened

was the markedly fatty liver.

I know, from the history that was provided,

that this lady died from heart failure,

but the findings in her heart are extremely marked

and the severity of them actually surprises me.

But before we did the postmortem there was no indication

that this lady had a fatty liver, and it's a possibility that,

even if this lady had not developed heart failure,

she may have gone on to develop liver failure

due to the fatty change within the liver.

We already knew a little about the way that this woman lived

and how she died.

What we couldn't have known before the postmortem was the extent

to which obesity would have ravaged her internal organs,

from the suffocating fluid in her lungs to her scarred kidneys,

creating a potent mix of life-threatening,

obesity-related disease.

I know that, health-wise,

being obese and being large, it just isn't good.

So if I can do this documentary to help other people to see what it's

doing to them, internally, for them to motivate theirself,

so that they can lose weight so that they, you know,

maybe they can have a child or maybe they can live a little bit longer,

a little bit happier.

That's why I'm doing this - to help people.

It's fine to have...

..like, politicians - like the Health Secretary or,

like, whoever or, like,

doctors on TV - saying everyone needs to eat less and move more,

kind of thing,

but until you can actually relate that to yourself,

then you can say, "Oh, that's not me.

"That's not going to happen to me."

I think a postmortem of someone with obesity

is going to be quite shocking

for a lot of people, who maybe think that they can deal with it.

And I've been there. I have been there as well.

"Deal with it tomorrow. I'm all right, right now.

"It's not affecting, you know... I don't need a machine to sleep.

"I can get around fine, you know?"

And just putting those choices off until tomorrow.

Time goes by so quickly, and...

..it's really important to think about, you know,

what's going on inside you now and where that might actually end up -

where you could end up.