The Nutritional Impact of Bariatric Surgery on Pregnancy

1. The Nutritional Impact of Bariatric Surgery on Pregnancy By: Dr. Abdullah Mijbil Almutawa Ph.D., MSc., R.D

2. Topics • Nutritional Risks after Surgery • Timing your Pregnancy • Weight Gain During Pregnancy • Calorie Intake • Protein Intake • Micronutrient Deficiencies • Special Considerations • References

3. Nutritional Risks After Surgery • Bariatric surgery increases the risk for nutrient deficiencies. The severity of risk depends on the type of procedure a person has had. Here's how they rank from lowest to highest risk: • Adjustable gastric banding (Restrictive bariatric procedure ) • Vertical sleeve gastrectomy (Restrictive bariatric procedures • Gastric bypass (Malabsorptive operation) • Bilio-pancreatic diversion (Malabsorptive operation)

4. Nutritional deficiencies are caused by decreased: • Absorption of nutrients from food • Secretion of stomach acid to aid in digestion and absorption • Intake of nutrients as a result of food intolerances, chronic nausea, vomiting and/or diarrhea

5. Timing Your Pregnancy • It is recommended that women wait 12-18 months after surgery before trying to conceive. Why ? • Rapid weight loss • Risk of nutritional deficiencies right after surgery.

6. Weight Gain During Pregnancy • The amount of weight a woman needs to gain during pregnancy is based on her body mass index (BMI) before pregnancy, according to the Institute Of Medicine, 2009.

7. Calorie Intake • Calorie recommendations for the pregnant bariatric patient include approx. 300 kcal/day above maintenance guidelines for bariatric surgery. • Most of the extra calories must come from protein.

8. Protein • Protein is the most important macronutrient for the bariatric pt. • To ensure adequate intake, protein must be consumed at the beginning of the meal. • Pregnancy (18 months after bariatric surgery): • 1.1g/kg/day of protein • Pregnancy (During the 18 months after surgery): • 1.5g/kg/day of protein • If needed, sugar-free protein shakes may be introduced.

9. Bariatric Food Guide Pyramid

10. Calcium • Calcium deficiency caused by: • Inadequate consumption • Malabsorption • Bypass procedures lead to Calcium deficiency as a result of excluding the duodenum and proximal jejunum from calcium absorption. • It is recommended to increase the intake from 1000 mg of calcium citrate with 10 mcg vitamin D to 2000 mg of calcium citrate with vitamin D (50–150 mcg). • Calcium Citrate does not require an acidic environment to be broken down. • Foods high in Ca: Dairy products – sesame seeds – Broccoli – Salmon – Sardine – tofu – Soya Beans – Chia seeds - Nuts.

11. Iron • In general, pregnant women require more Iron. • Iron in multi vitamin supplements(18mg)is not enough. • Most of the iron from foods like meats, legumes, and iron-fortified grains is absorbed in the stomach and the first part of the small intestine. • Patient must consult her doctor for Iron supplementation. • Calcium, Coffee, tea, and cola sodas can interfere with iron absorption (decaffeinated or caffeinated). • Unfortunately, there are no NUTRITIONAL recommendations for pregnant women after bariatric treatment YET.

12. Vitamin B12 • 18% of Vitamin B12 deficiency is found in patients post GS surgery (Gehrer). • Supplementation must be prescribed by doctor. • Foods high in Vitamin B12: • Liver • Salmon • Beef • Egg • Cheese • Fortified cereals

13. Folate • Halverson, in his study found 38% of by pass surgery patients are deficient in Folate. • Deficiency of Folate is less common in GS surgeries. • Daily intake of 1mg of Folate has been found to help prevent deficiency. • Foods high in Folate: Liver – Sunflower seeds – Leafy green vegetables – Peas – Beans – Asparagus.

14. Zinc • Zink should be considered especially after malabsorptive bariatric operations. • Low levels of zinc have been combined to premature deliveries, low birth weight, abnormal fetal development, and spina bifida. • Optimal dose of zinc required which is 15 mg a day. • Foods high in Zink: Bran – Low fat roast beef – Veal liver – pumpkin seeds – dark chocolate – Lamb – Peanuts.

15. Magnesium • Studies show low magnesium levels in women who have had a premature labor. • During pregnancy requirement for magnesium rises two times. • supplementation is obligatory at the dose of 200–1000 mg daily if states of deficiency occur or when symptoms of deficiency appear. • Foods high in Mg: Bran Rice – Oats – Watermelon seeds – Flaxseeds – Brazil nuts – Almonds.

16. Iodine • Iodine requirement during pregnancy rises twice during the first trimester. • WHO recommends its daily intake at the level of 250 mcg. • Only 150 mcg should be supplemented while the rest absorbed during nutrition. • Unfortunately, there are no recommendations for the pregnant women after bariatric treatment YET. • Foods high in Iodide: Sea Vegetables like Kelp – Cranberries – Yogurt – Potatoes – Dairy.

17. Special Considerations • To maximize the absorption of Calcium and Iron supplementation, the two should NOT be taken at the same time. • To avoid Constipation: • Increase fiber intake 25-35g/day • Moderate Exercise • Drink Two liters of water between meals • Sun exposure is a Must for adequate Vit D levels. (Vit D food fortification is never enough) • Chewing food slowly has a great effect on micronutrient absorption.

18. References • Blankenship J. Pregnancy after surgical weight loss: Nutritional care and recommendations. Weight Management Newsletter. 2005;3(1): 6-8. • Kushner R. Managing micronutrient deficiencies in the bariatric surgical patient. Obes Manage. 2005;1(5):203-206. • Raymond RH. Hormonal status, fertility, and pregnancy before and after bariatric surgery. Crit Care Nurs Q. 2005;28(3):263-268 • Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systemic review and meta-analysis. JAMA. 2004;292(14):1724-1737. • Sheiner E, Levy A, Silverberg D, et al. Pregnancy after bariatric surgery is not associated with adverse perinatal outcomes. Am J Obstet Gynecol. 2004;190(5):1335-1340. • C. B. Woodard, “Pregnancy following bariatric surgery,” Journal of Perinatal and Neonatal Nursing, vol. 18, no. 4, pp. 329–340, 2004. • L. F. Martin, K. M. Finigan, and T. E. Nolan, “Pregnancy after adjustable gastric banding,” Obstetrics & Gynecology, vol. 95, no. 6, pp. 927–930, 2000. • M. M. Kjaer and L. Nilas, “Pregnancy after bariatric surgery—a review of benefits and risks,” ActaObstetricia et GynecologicaScandinavica, 2012.

19. References • G. A. Decker, J. M. Swain, M. D. Crowell, and J. S. Scolapio, “Gastrointestinal and nutritional complications after bariatric surgery,” American Journal of Gastroenterology, vol. 102, no. 11, pp. 2571–2580, 2007. • R. Kushner, “Managing the obese patient after bariatric surgery: a case report of severe malnutrition and review of the literature,” Journal of Parenteral and Enteral Nutrition, vol. 24, no. 2, pp. 126–132, 2000. • 28.J. H. Beard, R. L. Bell, and A. J. Duffy, “Reproductive considerations and pregnancy after bariatric surgery: current evidence and recommendations,” Obesity Surgery, vol. 18, no. 8, pp. 1023–1027, 2008. • 13.S. Gehrer, B. Kern, T. Peters, C. Christofiel-Courtin, and R. Peterli, “Fewer nutrient Deficiencies after laparoscopic sleeve gastrectomy (LSG) than after Laparoscopic Roux-Y-gastric bypass (LRYGB)-a prospective study,” Obesity Surgery, vol. 20, no. 4, pp. 447–453, 2010.