1. By: Dr. Abdullah Mijbil Almutawa Ph.D., MSc., R.D

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

3.   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) Nutritional Risks After Surgery

4.   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 Nutritional deficiencies are caused by decreased:

5.   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. Timing Your Pregnancy

6.   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. Weight Gain During Pregnancy

7.   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. Calorie Intake

8.   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. Protein

9.  Bariatric Food Guide Pyramid

10.   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. Calcium

11.   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. Iron

12.   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 Vitamin B12

13.   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. Folate

14.   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. Zinc

15.   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. Magnesium

16.   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. Iodine

17.   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. Special Considerations

18.   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,” Acta Obstetricia et Gynecologica Scandinavica, 2012. References

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