Asking about if obesity is hereditary? Then, genes aren’t the most worrisome risk of obesity. An individual’s upbringing can be, the way the family raises, the daily food intake, importance placed on physical activity and how a person would take their behaviour model, are the bigger influences on likelihood of obesity than genes. Health is not valued till sickness comes, true isn’t? Obesity is not because it runs in the family!! It is because no one runs in the family!!!

Today, more than 95% of all chronic diseases is caused by food choice. Yes,being overweight is linked to a number of health and oral health diseases, including: heart disease, high blood pressure, diabetes, cancer, gallbladder and gallstones, breathing problems, such as sleep apnea (when a person stops breathing for a short time during sleep) and asthma, oral health problems such as caries, halitosis, poor oral hygiene, periodontal disease. Symptoms for obesity include breathlessness, Increased sweating, snoring, inability to cope with sudden physical activity, feeling tired, back and joint pain, low confidence and self-esteem, and feeling isolated.

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After being aware of the risks, proper health and oral hygiene should be maintained. And why is maintaining diet an important factor? Because a poor diet may result in lack of essential nutrients and vitamins thus potentially making it more difficult for your body to fight off an infection. A diet high in fat and calories, including large quantities of processed foods or sugar, and lack of physicalactivity, leads to obesity. Those same foods can cause oral health problems including gum disease, premature tooth loss and bad breath Our body craves for what is in our bloodstream. Wheat, sugar, alcohol, coffee and de-vitalized foods are designed to be addictive. Sugar being addictive – agreed. But how does sugar affect an individual’s health and oral health? Well, consuming sugar is bad for an individual, but consuming too much has become a norm and that can cause health issues. The only type of sugar the body needs is glucose, which it can make by breaking down carbohydrates, proteins and fats. When ingested, simple sugars are converted into plaque if not removed immediately. As plaque begins to accumulate on our teeth and gums, the risk of varying forms of gum diseases such a gingivitis and periodontitis, as well as tooth decay, may become inevitable.

In 2018, a study revealed that 170 children and young people have rotten teeth removed every day, undergoing general anaesthesia. That’s an unpleasant operation that is completely avoidable; we have got a lot of evidence to show that the main cause is excessive sugar. There are also links with type 2 diabetes, usually chronic disease seen in adults, but we are seeing more and more under the age of 25 these days.

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So, what an oral health care professional should be aware of? Dentists must be aware of how nutrition impacts general and oral health, and how dental treatment can impact patient’s nutritional status. Oral health is strongly influenced by the daily intake of food; on the other hand, oral health can also play a significant role in nutritional intake and general health status. The dental caries is also a chronic disease and may be depend on oral hygiene, high intake of sugar added to food, lifestyle factor, and host factors (salivary flow, buffer capacity and buccal microflora). Relationship between obesity and gum disease – we actually don’t know if this is a one-way or a two-way street. For example, conditions like diabetes, the relationship is bilateral. Periodontal disease will affect diabetes and diabetes will worsen periodontal disease, so that could be a possibility here. What are the other reasons of obesity affecting gums and what would be its risk factors? Because of various dietary habits and improper maintenance of oral hygiene, chronic periodontal infection is an inflammatory state that is described by a deviation in microbial environment and composition of subgingival plaque bio films and accelerated destruction of tooth supporting structures. Thus, low glycaemic diet may be beneficial to our oral health. Periodontal diseases are also influenced by various risk factors including aging, smoking, oral hygiene, socio-economic status, psycho social stress, osteopenia, osteoporosis and various systemic diseases, which signifies that periodontitis does not merely occur as a consequence of plaque deposition but is also coupled with various other host factors. Also, on examination, obese adolescents exhibited multiple carious teeth, higher plaque index, gingival inflammation, bleeding on probing and probing depth compared to normal weight subjects of similar age.

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An obese patient, whose lungs are often not large enough to lift heavy chest walls, can have trouble during breathing, especially when active. Also, during sleep the person might breathe through his/her mouth instead of nose, thus jaw is forced into an unnatural position for a longer period of time. This can lead to teeth grinding and development of an overbite, over jet or spacing between the anterior teeth.How can we, as dentists, help the obese patients? Dentists should include the evaluation of BMI in routine patient examination and eventually refer obese periodontal adolescents for weight reduction interventions like diet therapy, behavioural therapy, pharmacotherapy, so that they can have better control over periodontal inflammation.What are the practical considerations in dentistry? It can be difficult carrying out dental care for an obese patient: the maximum lifting weight for modern dental chair is approximately 140kg (23 stones). The position of anatomical landmarks may be less obvious if surrounded by fatty tissue, the landmarks for placement of an inferior alveolar nerve block can be impossible to palpate through excess soft tissue. It may be impossible to palpate cervical lymph nodes in a large neck. Also due to constant secretion of saliva, the mouth and teeth are rinsed and kept free off food debris and foreign particles, thus excess of buccal pad of fat hinders with self-cleansing action in the mouth. Because of lack of saliva present in the mouth, it can lead to dry mouth. Sip water frequently throughout the day and use alcohol-free antiseptic mouthwash daily for cure. A normal sized mirror is unsafe for retraction of soft tissues: a ‘lax’ tongue retractor can be useful.What is the alternative to conventional dental chair? Refer the patient to the hospital environment where the patient may be treated on an operating table or trolley. Another possible solution for obese patients is a custom-made chair such as DIACO dental chair. What is the difficulty faced during conscious sedation? When thinking about conscious sedation for obese patients, the potential difficulties in airway management and intravenous cannulation should be considered. The provision of inhalation sedation with nitrous oxide during which oxygen levels are maintained at or above 30% may be more appropriate. If intravenous sedation with midazolam is proposed, the overall benefit to the patient must be carefully weighed up against the increased likelihood of significant respiratory depression and the difficulties in managing a respiratory complication. New research suggests that the health of your mouth mirrors the condition of your body as a whole. A healthy smile can surely transform our visual appearance and the positivity of our mind-set.

‘Eat every two hours, sleep eight hours, have plenty of water and pray to keep calm. Most importantly, carry a smile on your face.’

About the author

Dr. Vishaj S. Maru is a dental surgeon. She studied dentistry at the D.Y. Patil School of Dentistry. She does clinical practice in Mumbai with a keen interest in academia and clinical dentistry.

Smart insulin- The major drawback of Type I is the dependence on regular external doses of insulin. While technology has made it more and more manageable with insulin pens, it results in the patient’s life to be largely centered around their medication. In 2015, researchers at the University of North Carolina devised a glucose-monitoring, insulin-delivery system using nanotechnology and biomedical engineering. The smart insulin patch consists of an array of tiny needles which can be used anywhere on the body to detect glucose levels and release insulin accordingly. The technology is currently undergoing revision and pre-clinical testing.

Islet transplant- Recovering healthy pancreas from cadavers and transplanting islet cells into the liver of the patient is an experimental procedure in practice since 2008 to assist with Type I. However, the success rate of this intervention is low due to rejection by the patient’s immune system and dependence on immune-suppressants which increase the risk of infection. It also does not completely reverse the patient’s insulin-dependence and requires regular low doses of insulin. A variation of this therapy at the University of Miami in 2017 was a successful transplant of pancreatic islet cells into the stomach lining of the patient which resulted in her complete remission from Type I and independence from constant insulin injections.

Stem cell therapy- With the evolution of cell biology techniques, we now have the ability to program immature cells to develop into a specific lineage of cells. Viacyte, a California based biomedical engineered a direct delivery device in April 2017, which when placed under the skin delivers stem cells into the bloodstream. These stem cells are programmed to home into the pancreas and develop into mature insulin-producing cells to replace those eliminated by the immune system. While this device is still in its nascent stages of the trial, it would be a life-saver for patients with highly variable glucose levels and severe risk of hypoglycemia.

Immature beta cells- Another variation of the stem cell therapy may be derived from our ability to now image the pancreatic tissue at unprecedented resolution. Scientists from the University of California, Davis identified an immature population of beta cells which can produce insulin but, unlike mature beta cells, are unaffected by the presence of glucose in the blood since they do not have glucose receptors. This discovery could lead to a deeper understanding of how beta cells function, and these immature cells can be manipulated to produce more insulin to keep the glucose levels in check. In February 2018, researchers at the University of Miami identified the exact anatomical location of pancreatic stem cells which can be stimulated to be glucose-responsive insulin-producing cells. Subsequently, University of California, San Francisco reported that beta cells can be ‘trained’ to adapt to a deficiency in oxygen and nutrients due to exposure before and during the transplantation, ideally ensuring an endless supply of insulin-producing beta cells.

IgM immunotherapy- The antibody IgM has been used as a diagnostic marker for Type I since the early 2000s. A team of researchers at the University of Virginia have found a new role for IgM as a vaccine against Type I autoimmunity. Injecting human IgM into diabetic mice resulted in a reduction of autoimmune reactivity, restoration of the balance of cells in the pancreas and reversal of Type I.

Methyldopa- This is a classic case of serendipity in science. Methyldopa is a clinically approved drug to treat hypertension. Scientists at the University of Colorado and the University of Florida screened all FDA-approved small molecules to check if any of them could prevent the autoimmune pathway of Type I from getting activated and Methyldopa was a successful candidate. After successful experiments on mice and a pilot clinical study, the drug can be developed as a vaccine to prevent Type I in those at risk.

Vaccines- Enteroviral infections are known to cause Type I in newborns by triggering an autoimmune response against islet beta cells. At the University of Finland, scientists have developed a vaccine that can potentially eliminate enteroviruses and thus prevent Type I. Another common vaccine B.C.G. used routinely against tuberculosis has been used by doctors at the Massachusetts General Hospital as a vaccine against Type I. They have been successful in a pilot clinical trial by reducing the insulin dosage to one-third of the patient’s initial requirement even after 5-10 years of the vaccination.

The DiRECT study from the Newcastle University, the UK with 300 diabetics aged 20-65 demonstrated that a severely calorie-restricted diet can result in remission of Type II in around 86% of the patients. This is a very promising result since there is a rapid increase in obesity and Type II. A strict weight loss intervention may be a means of both prevention and cure of Type II diabetes. Interestingly, Lorcaserin, a weight loss drug was reported by Harvard University to reduce the incidence of diabetes and the risk of hypoglycemia in patients being treated for obesity. This is supported by multiple recent findings from the neurobiology community that obesity results in activation of the microglia cells in the brain and results in impaired modulation of hormones and increased glucose levels or resistance to insulin and hence treating obesity would also reduce the likelihood of an array of metabolic disorders.

Wearable technology has translated to better diagnostic and monitoring devices for diabetes. We have had home kits for monitoring blood glucose levels since 1981, but almost all variants require blood by pricking the finger with a lancet. A proof-of-concept study in South Korea of a wearable glucose monitor in the form of contact lenses has been successfully tested in rabbits. The silicon lens has an outward facing LED which is switched off in response to high levels of glucose in the tears as detected by a sensitive nano-sized glucose monitor. While this technology needs more work before it can be available for humans, it is a step in the direction of real-time, non-invasive glucose monitoring. Another variant of the wearable monitor is a color-changing tattoo ink with liquid biosensors developed by MIT and Harvard Medical School which can detect changes in the glucose levels, pH or salt in the interstitial fluid between the cells. This study is currently in research mode with no plans for clinical trials. However, the possibility of using the human skin as an interactive display for physiological monitoring is extremely attractive for developing non-invasive diabetes management products as is the case with an armband that can monitor the glucose in sweat via an ionic sensor. The simple bioengineered product from the University of California, Berkeley is primed for continuous monitoring of not just glucose, but also sodium, potassium, body temperature and other physiological parameters with a fully integrated electronic system that can log and update the data into a mobile device, making non-invasive continuous monitoring a possibility.

The Mexican cavefish has been established as a new model organism for studying diabetes. It’s a blind fish that lives deep in the sea with no access to light and food for long periods of time. It has evolved to survive these harsh conditions by having an insatiable appetite and insulin receptors which do not respond in the presence of high blood sugar. As a result, the cavefish is severely diabetic but can function normally. While this physiological make-up is fatal to humans, understanding the function of the glucose regulation in cavefish may be vital to developing novel therapies for diabetes management and cure.

With medical technology advancing fast, we may be looking at a future with the potential to decrease healthcare costs worldwide to deal with diabetes in its diagnosis, management, and prevention.

Sahana Shankar is a Ph.D. candidate in Structural and Molecular Biology at Academia Sinica, Taiwan. When she is not extracting protein, she loves to travel, read and writes scicomm articles. Her passion is to translate the science in fascinating research papers in health and medicine into common parlance. She believes understanding the science behind the world around us is indispensable to our engagement with it. She has contributed to Brainwave, a children’s science magazine from the Amar Chitra Katha family and Newslaundry, an independent news portal.