By:
Dr. Abdullah Mijbil Almutawa
Ph.D., MSc., R.D
Topics

 Nutritional Risks after Surgery
 Timing your Pregnancy
 Weight Gain During Pregnancy
 Calorie Intake
 Protein Intake
 Micronutrient Deficiencies
 Special Considerations
 References
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)
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
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.
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.
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.
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.
Bariatric Food Guide Pyramid

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.
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.
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
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.
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.
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.
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.
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.
References
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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 metaanalysis. 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

 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.