Following Bariatric Surgery women should wait to conceive until they are at least 2 yrs post surgery, their weight has been stable for several months and their laboratory studies of vitamin, minerals and electrolytes levels are normal.  After weight has stabilized and blood work is normalized pregnancy after Bariatric Surgery can be achieved in a health manner for both mother and infant if monitoring is provided in relation to the surgery. We have discusses previously the importance of these issues in the following blogs here.

The following article by Lisa Rapaport re-emphasises this:
(Reuters Health) – Babies born less than two years after their mothers have weight loss surgery may face a higher risk of serious complications than infants delivered after more time has passed, a U.S. study suggests.

Because obesity is linked to fertility issues, undergoing so-called bariatric surgery to shed excess weight can make it easier for some women to get pregnant. But when these women do conceive, they are more likely to have premature or small infants that require intensive care than women in the general population. The remainder of the article can be found here.

Many people with obesity face infertility issues and seek infertility treatment or procedures. A recent article linked Vitamin D status to improved success rate of IVF (in-vito fertilization) & ICSI (interacytoplasmic sperm injection) in The Journal of Maternal-Fetal & Neonatal Medicine. It is important to check Vitamin D status for infertility treatment.

Here are the researchers results:

• Of the 252 females that completed the ICSI cycle, 42% became pregnant (n = 108).
• The mean vitamin D status was significantly higher in the pregnant group compared to the non-pregnant group (17.74 ng/ml vs 9 ng/ml, respectively; p = < 0.01).
• Vitamin D status was positively associated with both pregnancy (p = 0.001) and endometrial thickness (p < 0.01).
• Higher vitamin D levels was associated with a 21% increase odds of clinical pregnancy (p < 0.05).

The researchers concluded,

“Deficiency of 25-OHD in females hinders the accomplishment of optimal endometrial thickness required for implantation of embryo after ICSI.”

Following weight loss surgery (WLS) there can be improvement of fertility and for that reason we recommend two forms of birth control methods during the first 18-24 months following WLS or until weight loss has stabilized for several months. This helps to ensure the best outcome and health for the mother and infant.

In our office we continue to stress the importance of Vitamin D3 for bone and dental health, pregnancy, breastfeeding and several auto-immune diseases. Vitamin D has also been shown to reduce pre-term birth Duodenal Switch patients require a dry water miscible form of Vitamin D3 due to the fat malabsorption of the DS procedure. There are several past blog posts on the topic of Vitamin D and it’s associated nutrients.

This is not a substitution for formal medical advise that should be given to any patient by their bariatric surgeon and and OB/GYN familiar and experienced in the care of female patients with history of weight loss surgery.  This is information that we provide our patients when we are notified of their pregnancy.

We recommend and instruct to take all precautions to avoid getting pregnant within the first 18 to 24 months following  weight loss surgery. There is a significant amount of information about preferable birth controls, those to avoid, and additional pertinent information on our website.

Women who become pregnant after Weight Loss Surgery (WLS) should receive specific attention from their obstetrician because of the high risk nature of their pregnancy. Please make sure that you share this information with your OB/GYN.  Many patients have become pregnant and delivered health babies after Duodenal switch (DS) without difficulty, but you do need to be watched more closely. The scientific study favor patients getting pregnant after DS when their weight loss , and nutritional markers have stabilized (18 months or longer) and not before.  You also need to make sure you are taking all necessary vitamins, minerals and protein.

The first trimester is a very important time in the development of the fetus. Most organs and structures of the fetus are formed in the first trimester and therefore it is imperative that you pay close attention to your nutrition and your nutritional supplements.

You should continue to take your general multivitamins, other vitamins, minerals and  your calcium as you were taking prior to getting pregnant. In addition, you should also take what will be prescribed by your OB/GYN. Do not substitute your prenatal vitamin and any other supplements that you are prescribed by your OB/GYN with what you were prescribed by our office. Each patient’s situation is individualized and additional changes or supplementations may be needed based on the advice of your surgeon and OB/GYN. Multiple fetus pregnancies require additional vitamin, mineral and protein needs.

 A good prenatal vitamin should contain these:

Vitamin C – is essential for tissue repair, wound and bone healing and increases the body’s resistance to infection. For mother and baby this vitamin is essential daily as it is the agent that holds newly formed cells together. Helps baby to grow and builds strong bones and teeth. It is also instrumental in the body’s ability to absorb iron.

Vitamin D – promotes general growth. It maintains proper levels of calcium and phosphorus thus helping to build baby’s bones and teeth.

B Vitamins (thiamine, vitamin B6, riboflavin) – Thiamine converts carbohydrates into energy for mother and baby and is essential for baby’s brain development. It also aids in normal functioning of the nervous system and heart. If deficient during pregnancy, a baby is at risk for beriberi, a serious heart ailment. Vitamin B6 is also vital to develop your baby’s brain and nervous system. Riboflavin helps the body to produce energy. It promotes growth, good vision and healthy skin for mom and is important for the development of the baby’s bone, muscle and nervous system.

Folic Acid – is one of the B Vitamins that is needed to produce red blood cells. It helps synthesize DNA, is conducive to normal brain functions and is a critical part of spinal fluid, thus making it one of the few nutrients known to prevent neural tube defects such as spina bifida.

Calcium – your developing baby needs this mineral to grow strong bones and teeth, healthy nerves and muscles and to develop normal heart rhythm and blood clotting.

Potassium – is a mineral that helps maintain fluid balance in the body. This mineral helps regulate blood pressure, nerve impulses and muscle contractions.

Vitamin A – is important for cell growth, healthy skin and mucous membranes, and resistance to infections. It benefits red blood cell production in both mother and baby. This vitamin is essential for postpartum tissue repair.

Copper – a trace mineral found in all plant and animal tissues; it’s essential for forming red blood cells-a key process during pregnancy, when your blood supply doubles. Copper also aids tissue growth, glucose metabolism, and growth of healthy hair. It also helps form a baby’s heart, skeletal and nervous systems, arteries, and blood vessels.

Pantothenic Acid – is a trace mineral that regulates the body’s adrenal activity, antibody production, and the growth and metabolism of protein and fats. If you are deficient in this vitamin during pregnancy your baby’s growth may be slowed. This trace mineral is required for many essential functions, including growth, appetite regulation, digestion, wound healing, and the maintenance of collagen and elastin which may explain why some doctors think it may also help prevent stretch marks, one of the banes of pregnancy.

Iron – makes red blood cells, supplies oxygen to cells for energy and growth and builds bones and teeth. In pregnancy this mineral is so crucial because the body must produce extra blood to support the growing baby. During pregnancy you will need double the recommended daily allowance of iron to insure your health and that of your baby’s.

More often than not, many expectant mothers find taking a prenatal vitamin increases nausea in early pregnancy and sometimes beyond. If this happens, ask your doctor or midwife to change your formula or it may help to change how and when you take your vitamin. It is sometimes helpful to take your prenatal vitamins before you go to bed at night. If swallowing a large pill is difficult, cut it in half. In any event just like your mother said all those years, don’t forget to take your vitamin.

The following are important vitamin and nutritional components throughout the pregnancy but in particular the first trimester.

• Folic Acid: one of the B vitamins has been found to prevent neural tube defects (NTD). Increased intake of folic acid reduces the risk of NTDs such as anencephaly and spina bifida (open spine) by as much as 50 to 70% if women take enough before conception and in the early months of pregnancy. Take your general multivitamin and prenatal vitamin every day.

• Vitamin A: important to prevent blindness in the fetus. Vitamin A levels should be drawn and monitored prior to becoming pregnant and during the pregnancy to ensure adequate intake. You may need to take additional Vitamin A in a Dry water-soluble form such as Biotech Vitamin A 25. Please contact your surgeons office if your Vitamin A levels are below normal, or have not been drawn recently.

• Vitamin D: important for bone growth and formation. Vitamin D levels should be drawn prior to becoming pregnant and during the pregnancy to ensure adequate intake. Dry water-soluble form of Vitamin D3 such as Biotech D3 50. There is some research that adequate Vitamin D levels help protect against pre-term labor and an increase in preeclampsia risk.

• Protein: necessary in all structural formation of the fetus and the mother needs to increase protein intake by a minimum of 30 grams daily. Protein is need in nearly all fetal tissue formation.

The second and third trimesters are important in the growth, development and formation of bone structure and the overall growth of the fetus. It is important at this point to continue taking a minimum of 1500 mg Calcium (or what was prescribed by your surgeon), increased protein intake, your multivitamin, prenatal vitamin and any other supplements prescribed by your OB/GYN or surgeon. You may also need to increase your calorie intake with nutritious foods included in a healthy, well balance diet.

If you have any questions please contact your surgeon or the OBGYN. Your surgeon should also be willing to discuss any concerns that you or your OB/GYN may have with them.

Here is an discussion about the outcome of pregnancy after weight loss surgery.

In general we also advice against certain types of birth control because of the associated weight gain reported by the manufacturers. This is a decision that needs to be  made after considering all potential side effects including the potential weight related issues. Ease of use should not be the only variable.

As indicated at the beginning of this blog, the information provided here is not a substitute for your nutritional evaluation by your bariatric surgeon or an experienced OB/GYN.

Zinc is the most abundant intracellular trace mineral. The body does not have a zinc reserve due to the majority of the stores being in muscle, skin, and bone.  It is essential in the synthesis of muscle, DNA, cell membranes, cell signaling, nerve impulse, and hormone release.  It also plays a role in immune function, anti-oxidant, reproduction, blooding clotting, vision, growth, wound healing, thyroid function and insulin response to carbohydrate metabolism.  Zinc works with Vitamin A in several ways; converts retinol to retinal and is essential for liver synthesis of retinol binding protein that transports Vitamin A in the blood.  It is also important in maintaining levels of transport proteins; albumin, transferrin and pre-albumin. The zinc fingers have numerous functions, including Vitamin D , estrogen and androgen protein binding.

There are studies that show calcium citrate, calcium hydroxyapatite, calcium carbonate, calcium citrate malate have no effect on zinc absorption.  However, there are others show a decrease in its absorption and levels.

Higher doses of zinc can decrease copper absorption.  This does not appear to be the case at RDA doses of zinc.

Symptoms of deficiency include loss of appetite; poor growth; weight loss; lack of taste or smell; poor wound healing; skin problems such as acne, atopic dermatitis and psoriasis; hair loss; lack of menstrual period; night blindness; white spots on the fingernails; and depression.

People at risk for deficiency:

• Premature and low-birth-weight infants
• Older breast-fed infants and toddlers with inadequate intake of zinc-rich complementary foods
• Pregnant and breast-feeding women, especially adolescents
• People  receiving Total Parenteral Nutrition
• Malnutrition
•  Severe or persistent diarrhea
• Malabsorption Syndromes (Celiac, short bowel, WLS, etc)
• Inflammatory Bowel Disease
• Alcoholics
• Chronic Renal Disease
• Sickle Cell Anemia
• Medications and/or Supplements
• Elderly
• Vegetarians

Recommended Daily Allowance:

The high daily dose is 40 mg/daily. Common side effects of zinc include stomach upset, nausea, vomiting, and a metallic taste in the mouth. High doses of zinc can cause dizziness, headache, drowsiness, increased sweating, loss of muscle coordination, alcohol intolerance, hallucinations, and anemia.

• Male Adult: 11 mg/daily
• Adult Female: 8 mg/daily
• Pregnant or Breast Feeding Female: 11-13 mg/daily

Medications that may decrease zinc levels are ACE inhibitors, Penicillamine,  and Thiazide diuretics. Medications that increase Zinc are Amiloride.  Quinine and Tetracycline antibiotics decease the absorption of zinc.  Do not take Zinc with Immunosuppressant medications or Amiloride.

Inhibit absorption :

• Phytic Acid
• Oxalate
• Fiber
• Iron Supplement
• Copper
• Calcium Supplement
• Folate

This is not meant to be an all inclusive discussion.  Please refer to your physician and your laboratory studies before beginning any supplement regime.

Copper is a trace element. It is a co-factor and enzyme that regulates iron metabolism and is essential in cell production, immune function, cellular energy storage, anti-oxidative effect, nerve transmission and connective tissue and bone development. There are several research article linking dental bone health, alveolar bone and tooth enamel wear, to copper levels.

Copper’s co-ezymes work with transferrin to transport the iron for red blood cell formation. It is important to also look at copper levels and intake when a patient is at risk for deficiencies when diagnosing anemia. It is interesting to note that anemia can show an abnormal high level of copper on laboratory studies.

People at risk for Copper deficiency are:

• Cow milk fed infants
• Low birth weight infants
• Prolonged diarrhea
• Malnutrition
• Malabsorptive syndromes
• Menkes Syndrome
• Gastric or Weight loss surgery
• Short bowel syndromes
• Sprue’s disease
• Total Parenteral Nutrition need
• Celiac Disease
• Cystic Fibosis

Deficiency can impair red cell production, causing anemia,  and cause iron overload in organs, such as liver, brain, or retina. It may also cause a decrease in neutrilphils, a type of white blood cell. Osteoporosis can also be a side effect of low copper intake. There have also been reports of neurologic syndrome in at risk patient who are deficient.

Recommended Daily Allowance for the average male and female is 900 mcg/daily. Pregnant women daily RDA is 1,00mcg/daily and breastfeeding mothers RDA is 1,300 mcg/daily. The highest tolerable dose for the average person is 10,000 mcg/daily.

Medications and supplements that can increase levels are estrogen, birth control pills, and Tagamet. Medications and supplements that lower levels are allopurinol and nifedipine. Penicillamine may lower copper level and decrease amounts of pencillamine. Copper binds with NSAIDS and may increase their effect. Zinc supplementation over an extended period can decrease absorption of copper.

Toxicity symptoms are nausea, vomiting, abdominal pain, and  diarrhea.

This is not meant to be an all inclusive  or complete discussion. As always, consult with your physician based on your laboratory values regarding any supplementation.

Another article regarding Micro-elements for Bone Health

Pregnancy Webinar Post Bariatric Surgery