Monthly Archives: November 2017

Could Being Obese Make You Lose Your Teeth?

Having one’s teeth cleaned is not as bad as undergoing a root canal procedure, but certainly not as pleasant as getting a manicure. However, it does give one time to think of the implications of not doing so frequently, and the importance of carrying out the in-between cleaning tasks such as brushing, flossing and not eating caramel apples. Many of us may be not as compulsive about doing so as our dentist would like, but if we are also obese there is a greater cost to the health of our teeth and gums if the basic requirements of good dental hygiene are ignored.

No one disputes the adverse effects of consuming simple sugar on tooth decay. Ideally, if we indulge in eating or drinking sugar (as in soda or juice), we should race to the sink and brush our teeth immediately.  Dentists see the unfortunate consequences of not doing so, especially among those whose weight was gained by frequent consumption of sugar-rich snacks and drinks. Very few people will stop in the middle of a chocolate chip cookie or ice cream binge to floss and brush their teeth.

Obesity puts teeth and gums at risk for other reasons as well. Gastroesophageal reflux (aka acid reflux or heartburn) tends to be common, and causes teeth to be in contact with acid from the stomach, thereby contributing to the breakdown of teeth enamel. If the obesity is associated with depression or other mood disorders, the medications used to treat these disorders often leave the mouth extremely dry. The absence of saliva is also associated with dental decay. (Obesity Complicates Dental Health – Be Proactive!” Obesity Action Coalition, Stillwell, D.)

Patients who choose bariatric surgery to reduce the size of their stomach may be even more vulnerable to dental problems. Often vomiting occurs after this stomach surgery if too much food is put in the now tiny digestive organ. As with acid reflux, the teeth are coated with stomach acid, and enamel demineralization may result.  Moreover, according to Stillwell, an increased craving for sweets has been seen after surgery along with a significant tooth sensitivity that may make exposure to water or pressure uncomfortable. Patients who were not diligent about caring for their teeth before surgery are not likely to improve their dental hygiene afterwards, unless the importance of doing so is stressed.

Complicating care of the teeth and gums for someone struggling with obesity is this unpleasantness of attempting to fit an oversized body into a dental chair sized for smaller bodies. For someone with morbid obesity who finds walking difficult, getting to a dentist’s office is often physically painful. Added to this is the psychological pain of attempting to squeeze onto the reclining chair underneath the hanging trays and instruments. Stillwell suggests in his article that obese patients seek out dental offices equipped to handle their needs, but admits that there are very dental few practices that even consider this a problem.

Ironically, dentists were involved in developing and inserting devices in the mouth that would markedly reduce food intake to produce significant weight loss. Wiring of the teeth to prevent chewing was popular several years ago, but interest in using this approach declined rapidly in proportion to the rapid regain of weight when the jaws were freed. A modified version using a retainer-like device custom made to fit the roof of the patient’s mouth has been used with some success. The mouth can open only partially, so the patient has to take very small bites and consequently must eat very slowly. Since it takes about 15-20 minutes for the brain to realize that food has been consumed, the idea behind the retainer is that forced slow eating will produce fullness or satiety before excessive amounts of food can be consumed. Of course, it is also possible that the eater loses patience or becomes bored with the length of time it takes to complete a meal and goes on to do something else.  (“Are dentists involved in the treatment of obesity?” Karma, M.,Aw, G., and Tarakji, B., J Int Soc Prev Community Dent 2016 183-188) Once the retainer is removed, weight can be regained, unless the patient is willing to continue to eat very slowly. .

Although dental devices to reduce food intake may not be the most effective way of producing weight loss, the dentist may be an effective “first responder” in offering help and advice to obese patients. Most of us are unaware of the health of our mouths since it is almost impossible to see the state of our teeth and gums except for what stares back at us in the mirror. The possibility of losing our teeth and/or going through the pain and expense of periodontal surgery for gum disease is enough to motivate or frighten us into practicing what the dentist preaches.  Unlike a physician who makes the obese patient confront his or her weight, a dentist does not deal with the size of the patient’s body. The advice and suggestions about modifying food choices to decrease sugar intake and pointing out the association of gastric reflux with enamel erosion focuses on what is above the neck.  It is hard to ignore advice which, if not followed, may cause loss of one of our basic functions— chewing—as well as negatively affecting our appearance.  The simple suggestion about brushing in association with snacking might be enough to decrease between-meal food intake. The feel of a clean mouth and teeth is sometimes enough to prevent eating from immediately starting again.

And the dentist has an immense advantage over everyone else trying to help an individual improve food intake and lose weight: the patient can’t talk back.

Does Running Holiday Errands Count as Exercise?

“I‘m exhausted!” a friend told me when I bumped into her at the supermarket. “I spent the entire weekend running around doing errands.”

“Sounds like a good way of getting exercise and errands done at the same time,” I replied, knowing what the response would be. “Well, obviously I am not running,” she retorted. “But fighting the traffic in the mall parking lot and standing in line every store is so tiring. I don’t have the energy even to get to the gym.”

Holiday preparations, with its multitude of obligations and looming deadline of December 25th, seem to cause a frenzy of multitasking and soak up scarce free time. Even before Thanksgiving leftovers are consumed, the holiday to-do list is made and the running begins.

There is a high mental and physical cost to transforming ordinary life into one characterized by holiday decorations, buying and wrapping presents, sending cards, cooking, entertaining, hosting company and/or traveling. Since these tasks are added to those normally carried out each day, such as going to work, caring for family and social activities, the result is that time normally spent preparing and eating meals and exercising is drastically decreased. Indeed, going to the gym, a yoga class, or for a run seems like an indulgence done at the cost of cramming even more holiday obligations into remaining hours of the day or week. And for some, like my friend, the fatigue that comes with probably too little sleep, too much stress, too much shopping in malls with recirculated air, and too much waiting in traffic…it all makes sitting on a couch rather than on an exercycle seem like the only option at the end of the day.

Weight gain during the holiday season is so common that right after New Year’s Day, dieting kicks in. Gaining five pounds or more from Thanksgiving to the next year is not unusual, and holiday food and drink are major contributors to increased calorie intake. But even without the eggnog, sugar cookies, mayonnaise, sour cream or melted cheese dips, and fruit cake, weight would probably be gained. Lack of time leads to food court dining, fast food drive-ins, pizza, or nibbling all day on nutritionally weak snacks. Steamed vegetables, grilled fish and large salads are for January, not for December with its endless errands.

Frequent exercise classes or solitary workout routines followed by a shower, hair drying, and make-up applying is not compatible with a mind-set of counting down to Christmas.  And for those who exercise at home rather than at a health club, the convenience of having a piece of exercise equipment nearby is often ignored, because household tasks call more loudly than 30 minutes on the treadmill.

The approach to getting through the next few weeks without compromising sleep, weight, emotional well-being and fitness?

Schedule time to keep the body and mood healthy. You are not running a toy workshop in the North Pole and setting up a sleigh (rather than Amazon) delivery system by Dec 24. Which is to say that if there is a choice between getting enough sleep, or eating a salad, lean protein and high fiber carbohydrate, or taking a brisk walk or an exercise class, or making another dash to the mall, or baking one more batch of cookies? Choose exercise you want to do. Study after study has shown the positive and immediately impact that exercise has on decreasing stress and improving mood and cognition. Over the long term? Exercise can improve general health, decrease risks from heart disease, and perhaps even neurological diseases like Alzheimer’s.  A fatigued, stiff, grumpy body dragged to the gym unwillingly will not be the same after exercising. Paradoxically, the fatigue seems to lift….probably because increased blood flow oxygenates the muscles and brain. Stiffness from sitting in a car or standing in line goes away as the heat from the exercise makes the muscles more limber. Grumpiness disappears as well. People do not scowl at themselves in a health club; they may grunt or groan from the difficulty of their particular exercise, but somehow nasty moods go away (except if there are no towels when you leave the shower).

But the best part of literally (not figuratively) running or doing any other form of physical activity is that you are doing something for yourself. You are the beneficiary. You are the one who feels better, more energetic, less irritable or worried. The time you spend in exercise belongs to you.

Giving yourself the pre-holiday gift of time to take care of yourself is not something that is done easily. Guilt and anxiety over what has to be done, and what might not get done, may interfere with your healthy intentions: “I will make that salad or take a walk after I do (fill in the blank),” you say to yourself.

Putting your need for healthy food, exercise and sleep at the top of the long to-do list is hard. And yet, what better gift can you give to your family and friends than a cheerful, not sleepy, energetic, and unstressed you?

If We Had More Time to Eat, Would We Eat More?

The national eating day, Thanksgiving, is unusual in several respects. People who rarely cook spend hours in the kitchen transforming a rather ungainly raw bird into something beautifully edible and making artistic creations out of mashed sweet potatoes with marshmallows.  Stale bread that otherwise might be fed to the birds is turned into a complex dish that may or may not cook inside the turkey.  The table is formally set, and many courses with numerous dishes are served.  And the meal will take time.

Unless they have another Thanksgiving meal to go to, or feel compelled to Christmas bargain shop, guests are happy to dine leisurely. The meal may take considerably more than an hour, and rushing through is restricted to getting seconds on desserts before they are gone.  In this respect, Thanksgiving and other major holiday dining differs significantly from the way many of us eat the rest of the year.

That we eat more on Thanksgiving than on other days is not disputable.  Serving excessive amounts of food is appropriate, and we are expected to eat until we feel stuffed, and then eat some more. But would we eat so much if there were less time to do so?  Would we eat less if, like so many other days of the year, late afternoon/early evening activities and obligations shorten supper to a grab-and-chew type meal, rather than a sit-down dinner? Would we change the amount of food we eat if we actually sat and ate breakfast and lunch, rather than standing in line for take-out and then quickly consuming it before going back to work? Is eating quickly a prescription for too much, or too little food intake?

A few weeks ago I was having lunch with a relative who works for a large law firm. She kept looking at her watch as we stood in line for our salads at a food court. “They don’t like us to take more than 30 minutes for lunch,” she told me. “I hope I have time to eat.”

She is not alone. For many of us, eating is something we fit into our busy schedules often while we are doing something else, e.g. sending messages on our cell phone, working at our desks, or driving.

Hypothetically, if we have very little time to eat, we should be eating very little. A muffin or bagel for breakfast and two slices of pizza or a tuna wrap for lunch feels like fewer calories than a traditional breakfast of eggs and toast… or a lunch of baked chicken, potato, vegetables, roll and dessert. However, often when we choose foods that can be eaten quickly, we don’t notice that they can be calorically dense. A muffin or bagel with cream cheese may contain 600 calories, and a tuna salad sub with mayonnaise and cheese delivers as many calories as the hot lunch.

When we do not have time to eat, we may do it so quickly that we dump more food than necessary in our stomachs, like someone competing in an “All the hot dogs you can eat!” contest.  Sometimes when we gulp our food we don’t even notice how much we are eating. This is also true if we are multi-tasking while putting food in our mouths.

Sitting for a long time at a meal has its own perils. We may find it impossible to resist eating more than we intended to because we have the time and the food, especially the desserts, are there to tempt us. We are no longer hungry, yet the cookies or nuts or chocolate or pies are still on the table and it is hard, unless we are sitting on our hands, not to reach for them. A friend who often hosts long, leisurely meals told me that guests who resist eating dessert when she first serves it will often reach for the cake or cookies later on if they are all still sitting and chatting. Of course, meals that are interrupted by speeches between courses are a perfect prescription for overeating. The guest is a hostage to someone’s boring talk and eating seems to be the only way to endure it.

On the other hand, if we have the time to have an “appetizer” of carbohydrate, e.g., a roll, rice cakes, or crackers about 20 minutes before we start our meal, we may find ourselves eating less.  The carbohydrate potentiates the production of the brain chemical serotonin, and that in turn will make us feel somewhat full before the meal begins. This helps control how much we eat subsequently (a critical aid for dieters), and causes us to stop eating before we clean our plates.  But when time is limited, eating quickly and without the benefit of the satiating effects of serotonin, we could be eating more than we should.

Either too much or too little time can disrupt moderate and reasonable food intake. But certainly we should take the time to enjoy Thanksgiving for its own sake regardless of how much, or how long it takes to eat.

Who Cares for the Caregivers?

Her husband’s Parkinson disease had progressed significantly since we’d last seen each other and her stress progressed along with it. The kitchen counter was covered with pill containers and dosing schedules; the wheelchair was sitting by the ramp to the car and her husband waiting patiently for his aide to help him get dressed.

My friend, let’s call her Mandy, barely said hello before launching into a description of the difficulty she had getting her husband ready for bed the previous night. Apparently, he sat in the wrong chair in the living room while watching a football game. The chair did not have the jack that would propel him to his feet. It took two hours to get him upright and ready for bed in a tiny room near the kitchen. He could no longer climb stairs to their bedroom. She was exhausted and near tears.

Her situation is repeated in homes throughout the country where one spouse or child or elderly parent is losing physical, and often cognitive, strength due to neurological diseases that get worse over time. My friend is one of the fortunate ones. She is able to afford the service of professional aides and a physical therapist because of insurance purchased many years earlier when they were both healthy. Someone much stronger than she is can carry out the actual “heavy lifting.” That person is experienced in how to move a body that cannot move itself without great difficulty. But like so many others, she is dependent on the aide showing up, and she has to scramble to find people to fill in on weekends and holidays.

The Family Caregiver Alliance, a non-profit organization that provides support for people like my friend, a so-called informal caregiver, states that the numbers of unpaid caregivers in the U.S. in 2015 is about 43.5 million. Their caregiving, if paid for, would cost more than 470 billion dollars a year. More than 75 percent of the caregivers are women, and more than two-thirds of those receiving care are also women. It is estimated that 20 hours or more each week is devoted to the needs of the spouse, child, or parent so the informal caregiving is akin to an unpaid part-time job, with few entire days off.

Anyone who has filled this position knows that the tasks range far beyond giving out medicine at the right time. Often the number of tasks increase to the point where the patient needs help in just about every activity of daily living, from dressing and undressing to personal hygiene and being fed, and the responsibility of running the household, paying bills, and making medical appointments. The must-do list simply grows longer as the impairment from the disease increases.

The toll this takes on those who give the care is well-characterized and predictable. Just about every aspect of life is affected: sleep, physical and psychological well-being, work, socializing, pursuing personal interests, and hobbies. They all give way to the needs of the patient. Simply getting out of the house to do more than a quick trip to the supermarket or dentist is a rarity for many.

Mandy lives in a residential neighborhood only a few blocks from a library, stores, restaurants, and a supermarket so she sees other people when she takes her husband for an outing in his wheelchair. And she manages to get to a yoga class once a week when her husband is with his aide. But she has rarely has time to work on a collection of essays she has been writing, and her former volunteering activities have been abandoned. But she is fortunate; at least she is able to leave the house a few times a week.

Some diseases are easier to deal with than others, but no one gets to choose. When the caregiver is able to still share an emotional and cognitive life with his or her spouse or partner, the caregiving is bearable. But if the patient is unable to communicate and respond to the caregiver, it makes the caregiving even more difficult. Despite that it is the disease, and not the individual, who is responsible for the changed behavior; it may be extremely hard for the caregiver to hold onto that fact when dealing with unexpected anger, depression, apathy and sometimes non-recognition. In a study of the emotional burden carried by the caregiver, Croog, Burleson, and their team reported that anger and resentment was a common complaint along with lack of personal time and social isolation. There are support groups for the ‘”informal” caregivers, and they are geared toward helping with the specific problems presented by a disease, for example, Alzheimer’s, Parkinson’s, or ALS.

Over a cup of coffee, Mandy told that that the one thing she did not expect, as her husband’s symptoms worsened, was being alone so much of the time. “We have many friends; we both lived in this community for decades. But very few come to visit anymore, and we rarely are invited to other people’s homes because of lack of wheelchair access. And some people just avoid us because somehow they don’t know how to act around someone with a debilitating illness.”

Fortunately, my friend is strong and resilient, an excellent manager and a person who is able to meet the unending obligations she encounters. But she, like so many others in her situation, would like to have someone who understands and can share with her the difficult emotions and conflicting feelings she is experiencing in fulfilling the “in sickness” part of her wedding vows.

She too would like some care.


Spouse caregivers of Alzheimer patients: problem responses to caregiver burden. Croog SH, Burleson JA, Sudilovsky A, Baume RM. Aging Ment Health. 2006 Mar;10(2):87-100.