The dietary alterations necessary for bariatric surgery preparation and long-term changes are notably detrimental to oral health …

Body size is a complex issue. Its history is one of changing perceptions, social misconceptions, and altered language.

According to WHO, size self-perception is not always in line with the clinical definitions of normal weight, overweight and obesity. The medical term ‘obesity’ pathologises body shape by treating it as abnormal. It’s inappropriate to refer to someone as ‘obese’ – they are a person ‘suffering from obesity’.

Metabolic, or bariatric surgery is an effective treatment in severe cases, and it may be surprising to know that the first gastric bypass was performed in 1892 by Swiss surgeon Dr Cesar Roux. It wasn’t intended for weight loss, but as a treatment for patients with gastrointestinal obstructions.

Initially it seemed a successful procedure, but by 1911 it was discontinued because of high mortality rates and peptic ulceration.

It took until 1967 for surgical intervention to became a safer option for weight loss, and the term ‘bariatric’ was created from Greek root words, basically meaning ‘pertaining to weight treatment’.

There are four types of surgeries, all with the usual surgical risks, and every year, more than half a million people worldwide will undergo one of them.

Multidisciplinary teams are involved in this procedure. Physicians, physical therapists, nutritionists and psychologists – but not dentists, despite the oral health impact of the drastic change in diet, both before and after the operation.

What is now defined as a complex, multifactorial disease and a major determinant of disability, people with elevated Body Mass Index (BMI) were once considered little more than indulgent food addicts, lacking self-discipline.

A BMI of between 18 and 24.9 is deemed healthy. 25 to 29.9 fits the range of overweight, and anything above 30 rates as obesity.

Curiously, athletes, respected as some of the most disciplined of people, and with an average BMI of 22.9, often have issues with their dental health. Apparently the regular breathing through their mouth during training and exercise dries plaque, making it easier for cavities to form.

American Jon Brower Minnoch (1941-1983) with a BMI of 186 is recorded as the heaviest person to have ever lived; medically estimated to have weighed 635kg. However, in the crazy world of people as purely numbers, their humanity aside, in 2013 Saudi Khalid bin Mohsen Shaari tipped the scales 25kg under JB Minnoch, and his BMI was 204.

Inspiringly (or not, depending on personal body size politics) Khalid bin Mohsen Shaari is still a record holder. Losing 320kg in six months is the greatest weight loss in history.

Prior to its construct as a social problem in the 1900s, corpulence occupied a position of esteem, before Western culture dramatically shifted toward thinness as the ideal. Adiposity became democratised. The elite of industrialised countries decided that thinness equalled high status and a good education.

From an evolutionary perspective, for millions of years calories were scarce and physical movement was relentless, so the body was efficiently designed not to lose weight, but to hold the hard task of gaining it. According to biologists, that difficulty in getting enough calories is what drives the human preponderance for rich, fatty foods that we’ve never really stopped.

Although bariatric surgery is not an easy fix, twelve months post-op, between 70-90% of patients are satisfied with the outcome. A lifetime of dietary change is essential. Supplements are required on a daily basis to avoid nutritional deficiencies and there are strict limitations on meal portions, and fats and carbohydrate intake.

If that’s not challenging enough, recent studies confirm that the dietary alterations necessary for surgery preparation and long-term changes are notably detrimental to oral health.

With less fibre in the diet, pureed foods and much less chewing required overall, salivary markers showed impairment of acid buffers – essential for maintaining healthy tooth enamel. Although more frequent eating is mandatory, it’s not accompanied by increased tooth brushing so more biofilm forms on tooth surfaces and cavities result.

The study also determined through bacterial genome sequencing that permanent changes to microbiota diversity occurs, allowing a proliferation of the microorganisms responsible for periodontal disease.

So while body shape reduces and improves, dental issues significantly increase.

Never being hungry had power.

It’s immortalised in figurines and statuettes from 30,000 years ago, thought to be symbols of fertility and all that is good in hefty female form. The prehistoric Venus of Willendorf would be categorised today as having a BMI of probably 51.

All those ancient stone, ivory, horn, or clay sculptures have new research hypothesising another role: that they advocate the body type that would keep women warmer, and able to live through the Ice Age.

A 2020 paper published in Obesity, a peer-reviewed research journal and official journal of The Obesity Society, American researchers Miguel A. Lanaspa and John W. Fox maintain that these upper Palaeolithic figurines portraying women as having obesity, or pregnant, represent mankind’s adaptation to climate change.

From 38,000 to 14,000 years ago was one of the most arduous climatic periods in human history.

It was a period where humans faced falling temperatures, advancing glaciers, regional extinctions, food scarcity and nutritional stress. Worldwide, populations reduced.

Lanaspa and Fox’s study focussed on whether the more obese figurines came from sites closer to these glacial fronts because survival required sufficient nutrition for childbearing. They theorise that what they term as an “overnourished woman” became the ideal symbol of survival and beauty during these episodes of starvation and climate change in Palaeolithic Europe.

Part of their conclusion is the analysis of waist-to-hip, and waist-to-shoulder ratios of these fabulously fat figurines. With increased distance from the glaciers comes a decrease in the representation of fleshiness as fecundity.

Fat activists prefer the term ‘fat’. They are people who take pride in who they are, without separating that aspect of themselves. To claim the word that in the past has been so derogatively used against them is not just an act of rebellion, it is in their view, the most succinct and appropriate descriptor of their bodies. It’s a perspective from which ‘overweight’ implies a normality for flesh density; that having some exacting and replicable proportioning for height completely denies human diversity.

Just as there are many sides to size acceptance, there are many aspects to maintaining oral health and much research being done. Assessing a patient’s oral health before and after bariatric surgery is essential. The next steps for researchers in the field includes determining the best preventive and therapeutic intervention to resolve the now expected, oral health consequences.

The HEAS paradigm is a public health approach that endeavours to downplay weight loss as a goal for optimal physical function and happiness. It is Health At Every Size, with five principles: weight inclusivity, health enhancement, respectful care, eating for wellbeing, and life-enhancing movement.

Body positivity is a social movement that challenges beauty standards as a construct.

Everybody, regardless of gender, physical ability, skin tone and size is an appropriate and acceptable individual. Highly successful size 24 plus-size model and activist Tess Holliday has graced the cover of Cosmopolitan UK magazine in 2018. A milestone for the movement, it won Cover of the Year and in 2022 described herself as struggling with body image and an anorexic in recovery.

Just a snapshot of how complex all of this gets.

Maybe, in its simplest form, it’s about confidence. One way to gain it is by looking after your dental health. A stunning smile is a beautiful thing, no matter who we are.

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