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Ma G, Chen Y, Liu X, Gao Y, Deavila JM, Zhu M, Du M. Vitamin a supplementation during pregnancy in shaping child growth outcomes: A meta-analysis. Crit Rev Food Sci Nutr 2023; 63:12240-12255. [PMID: 35852163 PMCID: PMC9849478 DOI: 10.1080/10408398.2022.2099810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Abnormal fetal growth increases risks of childhood health complications. Vitamin A supplementation (VAS) is highly accessible, but literature inconsistency regarding effects of maternal VAS on fetal and childhood growth outcomes exists, deterring pregnant women from VAS during pregnancy. This meta-analysis aimed to analyze effects of vitamin A only or vitamin A + co-intervention during pregnancy in healthy mothers (MH) or with complications (MC, night blindness and HIV positive) on perinatal growth outcomes, also assess VAS dose impacts. The Cochrane Library, PubMed, ScienceDirect, Scopus, Embase and Web of Science databases were searched from inception to July 15, 2021. We covered subgroup analyses, including VAS in MH or MC within randomized controlled trial (RCT) or observational studies (OS). Fifty-five studies were included in this meta-analysis (426,098 pregnancies). Vitamin A decreased risk of preterm birth by 9% in MH-RCT (P < 0.001), by 62% in MH-OS (P = 0.029), by 10% in MC-RCT (P = 0.089); decreased LBW by 24% in MC-RCT (P = 0.032); increased neonatal weight in MC-RCT (SMD 0.96; P = 0.051). Besides, vitamin A + co-intervention decreased risks of preterm by 18% in MH-OS (P = 0.021); LBW by 25% in MH-OS (P < 0.001); by 32% in MC-RCT (P = 0.006); decreased neonatal defects by 33% in MH-OS (P = 0.064); decreased anemia by 25% in MH-OS (P = 0.0003); increased neonatal weight in MH-OS (SMD 0.51; P = 0.014); and increased neonatal length in MH-OS (SMD 1.83; P = 0.013). Meta-regression of VAS dose with individual outcomes was not significant, and no side effects were observed for VAS doses up to 4000 mcg (RAE/d). Regardless of maternal health conditions, VAS during pregnancy can safely and effectively improve fetal development and neonatal health even in mothers without VAD.
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Affiliation(s)
- Guiling Ma
- College of Agro-Grassland Science, Nanjing Agricultural University, Nanjing, Jiangsu, China
- Center for Reproductive Biology, Washington State University, Pullman, WA, USA
- Nutrigenomics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, USA
| | - Yanting Chen
- College of Animal Science & Technology, Nanjing Agricultural University, Nanjing, Jiangsu, China
- Center for Reproductive Biology, Washington State University, Pullman, WA, USA
- Nutrigenomics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, USA
| | - Xiangdong Liu
- Center for Reproductive Biology, Washington State University, Pullman, WA, USA
- Nutrigenomics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, USA
| | - Yao Gao
- Center for Reproductive Biology, Washington State University, Pullman, WA, USA
- Nutrigenomics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, USA
| | - Jeanene M. Deavila
- Center for Reproductive Biology, Washington State University, Pullman, WA, USA
- Nutrigenomics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, USA
| | - Meijun Zhu
- School of Food Science, Washington State University, Pullman, WA, USA
| | - Min Du
- Center for Reproductive Biology, Washington State University, Pullman, WA, USA
- Nutrigenomics and Growth Biology Laboratory, Department of Animal Sciences, Washington State University, Pullman, WA, USA
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Bretón I, Ballesteros-Pomar MD, Calle-Pascual A, Alvarez-Sala LA, Rubio-Herrera MA. Micronutrients in Pregnancy after Bariatric Surgery: A Narrative Review. J Clin Med 2023; 12:5429. [PMID: 37629473 PMCID: PMC10455502 DOI: 10.3390/jcm12165429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Bariatric surgery is increasingly used in women of childbearing age due to the rising prevalence of obesity and the effectiveness and availability of this treatment. Pregnancy in women with previous bariatric surgery deserves special attention. Weight loss induced by surgery reduces the risks that obesity poses to pregnancy. But on the other hand, decreased intake and malabsorption may increase the risk of malnutrition and micronutrient deficiency and negatively affect maternal and foetal health. The aim of this narrative review is to provide an updated analysis of the impact of different bariatric surgery techniques on mineral and micronutrient nutritional status during pregnancy and the possible effect on maternal-foetal health.
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Affiliation(s)
- Irene Bretón
- Department of Endocrinology and Nutrition, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
| | - María D. Ballesteros-Pomar
- Department of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, 24008 León, Spain
| | - Alfonso Calle-Pascual
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Clínico Universitario San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 28029 Madrid, Spain
| | - Luis Antonio Alvarez-Sala
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Miguel Angel Rubio-Herrera
- Department of Medicine, Facultad de Medicina, Universidad Complutense, 28040 Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Clínico Universitario San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, 28040 Madrid, Spain
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Micronutrient supplementation in pregnancies following bariatric surgery: a practical review for clinicians. Obes Surg 2021; 31:4542-4554. [PMID: 34304377 DOI: 10.1007/s11695-021-05546-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/15/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Patients who have undergone bariatric surgery are at high risk for nutritional deficiencies before and after surgery if no proper supplementation and close follow-up are maintained. As pregnancies after these surgeries are occurring more frequently, deficiencies imply risks for both mother and child. Nutritional needs for this specific population are different from that of patients with obesity or a non-bariatric population. This review provides a comprehensive summary of the most described vitamins and minerals during pregnancy, after bariatric surgery, and during pregnancy after bariatric surgery in order to summarize their specific needs and possible side effects and to provide a useful guideline to the involved caregivers.
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Onesimo R, Proli F, Leoni C, Contaldo I, Salerni A, Conti G, Tartaglia M, Zampino G. Embryopathy Following Maternal Biliopancreatic Diversion: Is Bariatric Surgery Really Safe? Obes Surg 2020; 31:445-450. [PMID: 32720264 DOI: 10.1007/s11695-020-04882-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/13/2020] [Accepted: 07/23/2020] [Indexed: 11/26/2022]
Abstract
Pregnancy after bariatric surgery is usually considered safe. Recently, a few studies reported that bariatric surgery represents a risk factor for birth defects. A case series of six patients, born from women who had undergone biliopancreatic diversion, is reported. The clinical pattern was characterized by psychomotor development delay (100%), microphthalmia (83%), growth retardation (66%), hearing loss (66%), and variable facial dysmorphism. Based on the clinical profile and symptoms reported by women during pregnancy, a causal association between maternal chronic post-surgical malabsorption, congenital anomalies, and neonatal outcome is proposed, with vitamin A deficiency representing a major causing factor. Educational follow-up support, continuous clinical monitoring, and appropriate nutritional assessment appear to be crucial to reduce the potential risk of congenital malformations and child disability.
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Affiliation(s)
- Roberta Onesimo
- Rare Disease and Birth Defects Unit, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Francesco Proli
- Rare Disease and Birth Defects Unit, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Chiara Leoni
- Rare Disease and Birth Defects Unit, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Ilaria Contaldo
- Child Neurology Unit, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Annabella Salerni
- Department of Ophthalmology, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Guido Conti
- Department of Head and Neck Surgery, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
- Catholic University of Sacred Heart, Rome, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giuseppe Zampino
- Rare Disease and Birth Defects Unit, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.
- Catholic University of Sacred Heart, Rome, Italy.
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Haseeb YA. A Review of Obstetrical Outcomes and Complications in Pregnant Women after Bariatric Surgery. Sultan Qaboos Univ Med J 2019; 19:e284-e290. [PMID: 31897311 PMCID: PMC6930040 DOI: 10.18295/squmj.2019.19.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/08/2019] [Accepted: 07/07/2019] [Indexed: 12/15/2022] Open
Abstract
Bariatric surgery (BS) is a novel treatment for weight reduction with longer lasting health benefits. This review aimed to summarise the available evidence regarding the fetomaternal outcomes and the most common challenges and complications in pregnancies following BS. Google Scholar (Google LLC, Mountain View, California, USA) and PubMed® (National Library of Medicine, Bethesda, Maryland, USA) databases were searched for articles published until December 2018. A total of 64 articles were included in this review and results showed that BS mitigates the risk of gestational diabetes mellitus, hypertensive disorders in pregnancy and fetal macrosomia. However, it can also have detrimental effects on fetomaternal health. There is paucity of data regarding small for gestational age intrauterine growth restriction, premature rupture of membranes and long-term effects on the children born to women who underwent BS.
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Affiliation(s)
- Yasmeen A Haseeb
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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For whom the bell tolls? It is time to retire the classic BPD (bilio-pancreatic diversion) operation. Surg Obes Relat Dis 2019; 15:1029-1031. [PMID: 31101565 DOI: 10.1016/j.soard.2019.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/17/2019] [Indexed: 01/11/2023]
Abstract
With the culture of safety and lowering risks that took place 20 years ago, sleeve gastrectomy has emerged as a procedure of choice. Hence, for super- and super-super-obese patients, there is a tendency these days to perform surgeries in 2 stages, and sleeve is the procedure of choice. Because sleeve is not part of a classic bilio-pancreatic diversion, it is unlikely that this operation will be done as a second stage, making this operation obsolete.
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Jans G, Matthys C, Bogaerts A, Lannoo M, Verhaeghe J, Van der Schueren B, Devlieger R. Maternal micronutrient deficiencies and related adverse neonatal outcomes after bariatric surgery: a systematic review. Adv Nutr 2015; 6:420-9. [PMID: 26178026 PMCID: PMC4496736 DOI: 10.3945/an.114.008086] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pregnant and postpartum women with a history of bariatric surgery are at risk of micronutrient deficiencies as a result of the combination of physiologic changes related to pregnancy and iatrogenic postoperative alterations in the absorption and metabolism of crucial nutrients. This systematic review investigates micronutrient deficiencies and related adverse clinical outcomes in pregnant and postpartum women after bariatric surgery. A systematic approach involving critical appraisal was conducted independently by 2 researchers to examine deficiencies of phylloquinone, folate, iron, calcium, zinc, magnesium, iodide, copper, and vitamins A, D, and B-12 in pregnant and postpartum women after bariatric surgery, together with subsequent outcomes in the neonates. The search identified 29 relevant cases and 8 cohort studies. The quality of reporting among the case reports was weak according to the criteria based on the CARE (CAse REporting) guidelines as was that for the cohort studies based on the criteria from the Cohort Study Quality Assessment list of the Dutch Cochrane Center. The most common adverse neonatal outcomes related to maternal micronutrient deficiencies include visual complications (vitamin A), intracranial hemorrhage (phylloquinone), neurological and developmental impairment (vitamin B-12), and neural tube defects (folate). On the basis of the systematically collected information, we conclude that the evidence on micronutrient deficiencies in pregnant and postpartum women after bariatric surgery and subsequent adverse neonatal outcomes remains weak and inconclusive.
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Affiliation(s)
- Goele Jans
- Departments of Development and Regeneration and
| | - Christophe Matthys
- Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium;,Departments of Endocrinology
| | - Annick Bogaerts
- University College Leuven, Hasselt, Belgium;,Center for Research and Innovation in Care, Department of Nursing and Midwifery Sciences, University of Antwerp, Antwerp, Belgium; and
| | - Matthias Lannoo
- Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium;,Abdominal Surgery, and
| | - Johan Verhaeghe
- Departments of Development and Regeneration and,Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium;,Departments of Endocrinology
| | - Roland Devlieger
- Departments of Development and Regeneration and Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium; Department of Obstetrics, Gynecology, and Reproduction, GZA, Wilrijk, Belgium
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8
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Dell’Agnolo CM, Cyr C, de Montigny F, de Barros Carvalho MD, Pelloso SM. Pregnancy after Bariatric Surgery: Obstetric and Perinatal Outcomes and the Growth and Development of Children. Obes Surg 2015; 25:2030-9. [DOI: 10.1007/s11695-015-1668-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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9
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Abstract
Bariatric surgery, and in particular, gastric bypass, is an increasingly utilized and successful approach for long-term treatment of obesity and amelioration of comorbidities. Nutrient deficiencies after surgery are common and have multiple causes. Preoperative factors include obesity, which appears to be associated with risk for several nutrient deficiencies, and preoperative weight loss. Postoperatively, reduced food intake, suboptimal dietary quality, altered digestion and absorption, and nonadherence with supplementation regimens contribute to risk of deficiency. The most common clinically relevant micronutrient deficiencies after gastric bypass include thiamine, vitamin B₁₂, vitamin D, iron, and copper. Reports of deficiencies of many other nutrients, some with severe clinical manifestations, are relatively sporadic. Diet and multivitamin use are unlikely to consistently prevent deficiency, thus supplementation with additional specific nutrients is often needed. Though optimal supplement regimens are not yet defined, most micronutrient deficiencies after gastric bypass currently can be prevented or treated by appropriate supplementation.
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Affiliation(s)
- Edward Saltzman
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA.
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10
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Modi AC, Zeller MH, Xanthakos SA, Jenkins TM, Inge TH. Adherence to vitamin supplementation following adolescent bariatric surgery. Obesity (Silver Spring) 2013; 21:E190-5. [PMID: 23404956 PMCID: PMC3630236 DOI: 10.1002/oby.20031] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 07/03/2012] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Adolescents with extreme obesity, who have undergone bariatric surgery, must adhere to many lifestyle and nutritional recommendations, including multivitamin therapy. Little is known about multivitamin adherence following adolescent bariatric surgery. DESIGN AND METHODS The present study aims to document self-reported and electronically-monitored adherence to multivitamins, determine convergence between self-report and electronic monitoring adherence for multivitamins, and identify barriers to multivitamin adherence for adolescents who have undergone bariatric surgery. RESULTS The study used a prospective, longitudinal observational design to assess subjective (self-reported) and objective (electronic monitors) multivitamin adherence in a cohort of 41 adolescents (Mean age = 17.1 ± 1.5; range = 13-19) who have undergone bariatric surgery at Cincinnati Children's Hospital Medical Center. Mean adherence as derived from electronic monitoring for the entire 6-month study period was 29.8% ± 23.9. Self-reported adherence was significantly higher than electronically monitored adherence across both the 1 and 6-month assessment points (z = 4.5, P < 0.000 and z = 4.0, P < 0.0001, respectively). Forgetting and difficulty swallowing multivitamins were the two primary barriers identified. While there are no established data regarding best practice for multivitamins following bariatric surgery, high rates of nonadherence to multivitamin therapy were observed in adolescents who had undergone bariatric surgery with forgetting and difficulty swallowing pills as reported barriers to adherence. CONCLUSION These high rates of nonadherence to multivitamin therapy should be considered when devising treatment and family education pathways for adolescents considering weight loss surgery.
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Affiliation(s)
- Avani C Modi
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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11
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Abstract
The dramatic increase in the prevalence of obesity in women of reproductive age has resulted in approximately 1 in 5 women being obese when they conceive. Bariatric surgery has been shown to be the most effective long-term weight loss strategy in obese women in this age group. Clinicians should be aware of the effects of bariatric surgery on fertility and future pregnancies. Regarding certain complications, pregnancy after bariatric surgery appears to be safer than pregnancy in the obese. In patients where nutrition is properly maintained and monitored, the risks for obesity-related obstetric complications, such as gestational diabetes mellitus and hypertension, are significantly reduced, but possibly at the expense of an increase in neonates born small-for-gestational-age. At the present, definitive conclusions cannot be drawn concerning the risk for Caesarian delivery, differences in type of bariatric procedure, or the optimal surgery-to-conception interval.
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Affiliation(s)
- Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 151, Beer-Sheva, Israel.
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13
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Abstract
Lifestyle intervention programmes often produce insufficient weight loss and poor weight loss maintenance. As a result, an increasing number of patients with obesity and related comorbidities undergo bariatric surgery, which includes approaches such as the adjustable gastric band or the 'divided' Roux-en-Y gastric bypass (RYGB). This Review summarizes the current knowledge on nutrient deficiencies that can develop after bariatric surgery and highlights follow-up and treatment options for bariatric surgery patients who develop a micronutrient deficiency. The major macronutrient deficiency after bariatric surgery is protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.
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Affiliation(s)
- Bikram S Bal
- Department of Medicine, Washington Hospital Center, POB North, Suite 3400, 106 Irving Street Northwest, Washington, DC 20010, USA
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Donadelli SP, Junqueira-Franco MVM, de Mattos Donadelli CA, Salgado W, Ceneviva R, Marchini JS, Dos Santos JE, Nonino CB. Daily vitamin supplementation and hypovitaminosis after obesity surgery. Nutrition 2012; 28:391-6. [DOI: 10.1016/j.nut.2011.07.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 06/26/2011] [Accepted: 07/19/2011] [Indexed: 02/08/2023]
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Dalfrà MG, Busetto L, Chilelli NC, Lapolla A. Pregnancy and foetal outcome after bariatric surgery: a review of recent studies. J Matern Fetal Neonatal Med 2012; 25:1537-43. [PMID: 22339055 DOI: 10.3109/14767058.2012.663829] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.
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Affiliation(s)
- Maria Grazia Dalfrà
- Department of Medical and Surgical Sciences, Padova University, Padova, Italy
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Ocón J, Cabrejas C, Altemir J, Moros M. Phrynoderma: a rare dermatologic complication of bariatric surgery. JPEN J Parenter Enteral Nutr 2012; 36:361-4. [PMID: 22269897 DOI: 10.1177/0148607111422067] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Biliopancreatic diversion is a predominantly malabsorptive bariatric procedure that can lead to the development of several nutrition complications, including fat-soluble vitamin deficiencies. Routine supplementation with vitamins and trace elements and a strict medical follow-up are essential to prevent these nutrition risks. Vitamin A deficiency is common after bariatric surgery but rarely causes clinical symptoms. Case reports have described ophthalmological and fetal complications associated with vitamin A deficiency after malabsorptive bariatric surgery. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. The simultaneous occurrence of phrynoderma and ocular symptoms secondary to hypovitaminosis A after bariatric surgery is exceptional. The authors describe a man who presented follicular hyperkeratosis with nyctalopia and xerophthalmia that had appeared 1 year after biliopancreatic diversion. He admitted poor compliance with diet and daily supplementation of vitamins and oligoelements. Serum vitamin A levels were decreased. Treatment with high doses of vitamin A was associated with a clear improvement of cutaneous and ocular lesions with complete resolution after 2 months. The patient was readmitted 2 years later because of the reappearance of cutaneous lesions and micronutrient deficiency. Revisional bariatric surgery was performed. The authors review and discuss the relationship between phrynoderma, malnutrition, and vitamin A deficiency.
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Affiliation(s)
- Julia Ocón
- Service of Endocrinology and Clinical Nutrition, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain.
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11-Year follow-up in biliopancreatic diversion for recurrent pancreatitis due to lipoprotein lipase deficiency. J Pediatr Gastroenterol Nutr 2011; 52:499. [PMID: 21415674 DOI: 10.1097/mpg.0b013e3181f01bb9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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18
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Thorell A. Clinical Nutrition University: Nutritional support after bariatric surgery. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.eclnm.2011.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gilchrist H, Taranath DA, Gole GA. Ocular malformation in a newborn secondary to maternal hypovitaminosis A. J AAPOS 2010; 14:274-6. [PMID: 20603063 DOI: 10.1016/j.jaapos.2010.01.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2009] [Revised: 01/27/2010] [Accepted: 01/28/2010] [Indexed: 12/11/2022]
Abstract
We report a case of microphthalmia, inferior adherent leukoma, and optic nerve hypoplasia in an infant whose mother underwent biliopancreatic diversion surgery for obesity 7 years before his birth. The pregnancy was complicated by severe, maternal hypovitaminosis A despite oral supplementation. The infant was found to have undetectable serum vitamin A levels in the perinatal period. At 8 weeks of age, the infant underwent sector iridectomies. At 9 months of age, electroretinography suggested rod dysfunction. His visual performance is poor.
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Affiliation(s)
- Hannah Gilchrist
- Department of Ophthalmology, Royal Children's Hospital, Brisbane, Queensland, Australia
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Eerdekens A, Debeer A, Van Hoey G, De Borger C, Sachar V, Guelinckx I, Devlieger R, Hanssens M, Vanhole C. Maternal bariatric surgery: adverse outcomes in neonates. Eur J Pediatr 2010; 169:191-6. [PMID: 19562372 DOI: 10.1007/s00431-009-1005-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 05/19/2009] [Indexed: 01/20/2023]
Abstract
BACKGROUND The obesity epidemic in developed countries has led to an increased prevalence of obese women of reproductive age. As maternal obesity has far-reaching consequences for both mother and child, the consensus is that weight loss before pregnancy will reduce obesity-related morbidity and mortality. Therefore, an increasing number of women become pregnant after undergoing obesity surgery. RESULTS AND DISCUSSION From the literature, data shows that perinatal outcome after bariatric surgery is generally considered as favourable for both mother and child. Only a few case reports highlight the possibility of side effects on the foetus and neonate. We report on five cases with severe intracranial bleeding, all possibly related to vitamin K deficiency following maternal bariatric surgery. CONCLUSION These reports indicate that careful nutritional follow-up during pregnancy after obesity surgery is mandatory, because nutritional deficiencies such as vitamin K deficiency can lead to life-threatening bleeding.
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Affiliation(s)
- A Eerdekens
- Department of Neonatology, Division of Mother and Child, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium
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Kang L, Marty D, Pauli RM, Mendelsohn NJ, Prachand V, Waggoner D. Chondrodysplasia punctata associated with malabsorption from bariatric procedures. Surg Obes Relat Dis 2010; 6:99-101. [DOI: 10.1016/j.soard.2009.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2009] [Revised: 04/30/2009] [Accepted: 05/06/2009] [Indexed: 10/20/2022]
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Abstract
The presence of nutritional deficiencies in overweight and obesity may seem paradoxical in light of excess caloric intake, but several micronutrient deficiencies appear to be higher in prevalence in overweight and obese adults and children. Causes are multifactorial and include decreased consumption of fruits and vegetables, increased intake of high-calorie, but nutritionally poor-quality foods, and increased adiposity, which may influence the storage and availability of some nutrients. As the obesity epidemic continues unabated and the popularity of bariatric surgery rises for severely obese adults and adolescents, medical practitioners must be aware of pre-existing nutritional deficiencies in overweight and obese patients and appropriately recognize and treat common and rare nutritional deficiencies that may arise or worsen following bariatric surgery. This article reviews current knowledge of nutritional deficits in obese and overweight individuals and those that commonly present after bariatric surgery and summarizes current recommendations for screening and supplementation.
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Affiliation(s)
- Stavra A. Xanthakos
- Assistant Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, Medical Director, Surgical Weight Loss Program for Teens, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, Olbers T, Bøhmer T. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr 2009; 90:15-22. [PMID: 19439456 DOI: 10.3945/ajcn.2009.27583] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Bariatric surgery is widely performed to induce weight loss. OBJECTIVE The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.
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Affiliation(s)
- Erlend T Aasheim
- Department of Medicine, Oslo University Hospital Aker, Oslo, Norway.
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Pereira S, Saboya C, Chaves G, Ramalho A. Class III obesity and its relationship with the nutritional status of vitamin A in pre- and postoperative gastric bypass. Obes Surg 2009; 19:738-44. [PMID: 18392900 DOI: 10.1007/s11695-008-9478-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Accepted: 02/25/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Epidemiological findings have shown the rise of the prevalence of obesity in several segments of the world population, and more recent evidences point to a possible association with vitamin A deficiency (VAD). The aim of this study was to investigate vitamin A nutritional status in individuals with class III obesity in the preoperative period and 30 and 180 days after Roux-en-Y gastric bypass, correlating these findings with lipid profile and body mass index (BMI). METHODS The sample was composed of class III obese individuals, males and females, in the preoperative period (T1) and 30 (T2) and 180 days (T3) after bariatric surgery with 5,000 IU of supplementation of retinol acetate. Vitamin A nutritional status was assessed through biochemical indicators (retinol and beta-carotene serum levels), which were quantified by high-performance liquid chromatography with an inadequacy cutoff of <1.05 micromol/L and >or=40 microg/dL, respectively. RESULTS Out of the 114 assessed patients, the mean age was 36.9+/-11.6 years and BMI was >or=40 kg/m2. The prevalence of VAD was 14%, being 37.5% in T1, 50.8% and 67.8% in T2, and 52.9% and 67% in T3, according to retinol and serum beta-carotene, respectively. A decrease of retinol and beta-carotene serum levels was observed with BMI increase in T1. An increase of very-low-density lipoprotein cholesterol (VLDLc) and triglycerides was verified with the increase of retinol, being VLDLc in T3 and triglycerides in T1 and T2. In T1, high-dense lipoprotein cholesterol presented a positive and significant correlation with beta-carotene and a negative and significant correlation in T3. CONCLUSION High prevalence of VAD in the preoperative period and in 30 and 180 postoperative days, even during supplementation, with higher inadequacy of beta-carotene in all the three studied time periods, probably occurred because of its bioconversion to retinol due to the increased demand to which those individuals were exposed. It is suggested that the oral intake supplementation does not present the expected impact, and the need of assessing the nutritional status of vitamin A in the pre- and postoperative Roux-en-Y gastric bypass is emphasized. High prevalence of VAD in T1, with severity in T2 and T3, corroborates the utilization of the cutoff of <1.05 micromol/L as a VAD marker in the studied segment and reinforces its utilization as a tool in clinical practice to identify VAD in morbid obese patients who underwent bariatric surgery.
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Affiliation(s)
- Silvia Pereira
- Vitamin A Research Group, Universidade Federal do Rio de Janeiro, Rua Dona Mariana, 143/F11-Botafogo, Rio de Janeiro, Rio de Janeiro, CEP: 22280-020, Brazil.
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Guven S. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009; 17 Suppl 1:S1-70, v. [PMID: 19319140 DOI: 10.1038/oby.2009.28] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.
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Chirurgie bariatrique et obstétrique. ACTA ACUST UNITED AC 2009; 38:107-16. [DOI: 10.1016/j.jgyn.2008.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 11/27/2008] [Accepted: 12/03/2008] [Indexed: 02/03/2023]
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Skogøy K, Laurini R, Aasheim ET. [Pregnancy shortly after bariatric surgery]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:534-6. [PMID: 19291886 DOI: 10.4045/tidsskr.09.34019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Bariatric surgery is increasingly used to treat morbidly obese patients. Fertility in women may be enhanced after these procedures, owing to substantial weight loss and possibly a decreased absorption of oral contraceptives. We report a pregnancy that occurred two months after biliopancreatic diversion with duodenal switch in a 32-year-old woman. She subsequently developed haemolysis, elevated liver enzymes and low platelets count (HELLP) syndrome and had a weight loss of 43 kg (from the bariatric procedure) until the infant was delivered preterm by caesarean section (due to low activity). The infant was small in relation to the gestational age, with a weight of less than 50 % of the expected (780 g at 29.6 weeks). Histological examination demonstrated a small placenta with insufficient spiral artery trophoblast infiltration, possibly caused either by severe preeclampsia or by maternal nutritional deficiencies. Severe metabolic aberrations may complicate pregnancies after malabsorptive bariatric surgery. Patient preparations before weight-loss operations should include information on fertility and birth control in the postoperative period. Protocols for monitoring of patients that become pregnant after bariatric surgery are needed.
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Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical review. Hum Reprod Update 2009; 15:189-201. [PMID: 19136457 DOI: 10.1093/humupd/dmn057] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND After many cycles of weight loss and weight gain, more and more morbidly obese patients undergo bariatric surgery, like gastric banding or gastric bypass, as the ultimate treatment for their obesity-problem. Since women of reproductive age are candidates for bariatric surgery, concerns arise regarding the potential impact on future pregnancy. METHODS English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding. RESULTS The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive. CONCLUSIONS Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.
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Affiliation(s)
- Isabelle Guelinckx
- Department of Nutrition-Preventive Medicine, Leuven Food Science and Nutrition Research Centre, University Hospital Gasthuisberg, Catholic University Leuven, Belgium.
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract 2008; 14 Suppl 1:1-83. [PMID: 18723418 DOI: 10.4158/ep.14.s1.1] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis 2008; 4:S109-84. [PMID: 18848315 DOI: 10.1016/j.soard.2008.08.009] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.
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ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis 2008; 4:S73-108. [PMID: 18490202 DOI: 10.1016/j.soard.2008.03.002] [Citation(s) in RCA: 286] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 03/12/2008] [Indexed: 12/13/2022]
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Karmon A, Sheiner E. Pregnancy after bariatric surgery: a comprehensive review. Arch Gynecol Obstet 2008; 277:381-8. [PMID: 18299862 DOI: 10.1007/s00404-008-0608-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 02/14/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Obesity continues to be a global epidemic, and strong evidence exists linking it with gestational complications such as macrosomia, hypertensive disorders of pregnancy, gestational diabetes, and cesarean section. Bariatric surgery, a highly effective treatment for obesity, may prevent such complications in subsequent pregnancies. OBJECTIVE This review seeks to describe the risks and benefits of post-bariatric procedure pregnancies, in comparison to both community and obese cohorts. RESULTS A thorough review of the literature suggests that post-surgery women are not at increased risk for poor perinatal outcomes, and moreover their risks for many obesity-related gestational complications are reduced after bariatric surgery. Data regarding fertility after bariatric surgery are quite ambiguous, however, and studies exist demonstrating both positive and negative associations between weight loss procedures and fertility. CONCLUSIONS Clinicians should be aware that data collected on this subject were often gathered from post-op pregnant women provided with good prenatal care and screening for nutritional deficiencies. Although pregnancy after bariatric surgery appears to be safe, providers should take extra care to properly monitor their post-op pregnant patients for appropriate weight gain and nourishment.
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Affiliation(s)
- Anatte Karmon
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Roehrig HR, Xanthakos SA, Sweeney J, Zeller MH, Inge TH. Pregnancy after gastric bypass surgery in adolescents. Obes Surg 2007; 17:873-7. [PMID: 17894144 DOI: 10.1007/s11695-007-9162-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is no previous research or documentation of the incidence of pregnancy or pregnancy outcomes in female adolescents after undergoing bariatric surgery. METHODS Retrospective chart reviews were conducted for female patients who had bariatric surgery in our adolescent program from 2001-2007. Descriptive and clinical data were abstracted from the medical records, including data from the initial assessment and from follow-up clinic visits pre- and postoperatively. RESULTS 47 adolescents (age <19 years) underwent Roux-en-Y gastric bypass (RYGBP). 7 pregnancies occurred in 6 Caucasian females and resulted in 6 reported healthy term deliveries (1 pending). 6 of the 7 pregnancies were conceived between 10 and 22 months following surgery. In this small cohort of adolescent females, the pregnancy rate was 12.8%. CONCLUSIONS The program pregnancy rate for adolescent females in this cohort was greater than anticipated, compared with national pregnancy rates for age and race-matched females in the USA. Risk factors that may contribute to an increased incidence of adolescent pregnancy in this unique bariatric population are unclear, but may include poor adherence to contraceptive therapy and psychosocial factors. Further research is required to define risk factors, improve adherence to contraceptive therapy, and encourage postponement of pregnancy after surgery.
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Affiliation(s)
- Helmut R Roehrig
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229-3039, USA.
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Miller RJ, Xanthakos SA, Hillard PJA, Inge TH. Bariatric surgery and adolescent gynecology. Curr Opin Obstet Gynecol 2007; 19:427-33. [PMID: 17885457 DOI: 10.1097/gco.0b013e3282efb285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the impact of bariatric surgery on gynecologic complications in the context of the extremely obese adolescent and reviews contraceptive considerations before and after adolescent bariatric surgery. RECENT FINDINGS Eighteen percent of children and adolescents have a body mass index greater than the 95th percentile, with 4% of adolescents being greater than the 99th percentile. Gynecologic morbidities identified in obese adolescents include anovulatory complications such as acute menorrhagia, polycystic ovary syndrome and endometrial hyperplasia, and cancer. When conventional dietary and behavioral therapy fail to result in weight loss, specific criteria have been identified to justify bariatric surgery in extremely obese adolescents. Bariatric surgery in adult women often results in resumption of ovulatory menses, resolution of clinical and laboratory evidence of hyperandrogenism, and return of fertility. Adolescents are at risk for unintended pregnancies, and there are special concerns regarding pregnancy in bariatric patients. Specific contraceptive methods have particular potential risks, benefits, and drawbacks for use in obese adolescents. SUMMARY Clinicians who provide care for extremely obese adolescents must be aware of the potential for gynecologic morbidities including polycystic ovary syndrome, dysfunctional bleeding and endometrial hyperplasia, expected gynecologic and fertility outcomes of weight loss surgery for teens, as well as the implications on contraceptive options.
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Affiliation(s)
- Rachel J Miller
- Division of Adolescent Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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Landsberger EJ, Gurewitsch ED. Reproductive implications of bariatric surgery: pre- and postoperative considerations for extremely obese women of childbearing age. Curr Diab Rep 2007; 7:281-8. [PMID: 17686404 DOI: 10.1007/s11892-007-0045-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Extreme obesity remains a frustrating and formidable disease, with most sufferers requiring surgical intervention in order to achieve long-term, sustained weight loss. Most bariatric procedures today are performed on women, many of whom are of reproductive age; yet minimal evidence exists to guide clinicians in the care of such women before, during, and after pregnancy. This review outlines the fundamental nutritional and surgical alterations of the most commonly performed bariatric procedures with the aim to elucidate a physiologically sound approach to counseling and management of extremely obese women of childbearing age who are either contemplating or have already undergone bariatric surgery. Preconception, pregnancy, and lactation guidelines are offered based on available evidence. Outstanding questions are highlighted for further investigation.
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Affiliation(s)
- Ellen J Landsberger
- Department of OB/GYN and Women's Health, Division of Maternal-Fetal Medicine, Weiler Hospital of Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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Chaves GV, Pereira SE, Saboya CJ, Ramalho A. Nutritional Status of Vitamin A in Morbid Obesity before and after Roux-en-Y Gastric Bypass. Obes Surg 2007; 17:970-6. [PMID: 17894159 DOI: 10.1007/s11695-007-9152-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The objective of the present study was to identify the factors which contribute to the appearance and/or aggravation of Vitamin A Deficiency (VAD) in individuals with morbid obesity in the pre- and postoperative stages of Roux-en-Y gastric bypass (RYGBP). Bibliography searches were done in the data-bases of Medline and Lilacs, published in the last 35 years, priorizing the studies which assessed VAD through serum levels of retinol. The principal factors identified as contributors to VAD were oxidative stress, deficiency of other nutrients, lipid malabsorption in the postoperative stage, insufficient intake of lipids and food sources of Vitamin A, and presence of nonalcoholic fatty liver disease. The investigation of the nutritional status of Vitamin A in those individuals may foment intervention strategies easily incorporated in already established routine procedures, aiming to reduce VAD rates, which will reflect upon those individuals' quality of life.
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Affiliation(s)
- Gabriela Villaça Chaves
- Research Group on Vitamin A, Instituto de Nutrição Josué de Castro, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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Folope V, Coëffier M, Déchelotte P. [Nutritional deficiencies associated with bariatric surgery]. ACTA ACUST UNITED AC 2007; 31:369-77. [PMID: 17483773 DOI: 10.1016/s0399-8320(07)89395-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Morbidly obese patients often have nutritional deficiencies, particularly in fat-soluble vitamins, folic acid and zinc. After bariatric surgery, these deficiencies may increase and others can appear, especially because of the limitation of food intake in gastric reduction surgery and of malabsorption in by-pass procedures. The latter result in more important weight loss but also increase the risk of more severe deficiencies. The protein deficiency associated with a decrease in the fat-free mass has been described in both procedures. It can sometimes require an enteral or parenteral support. Anemia can be secondary to iron deficiency, folic acid deficiency and even to vitamin B12 deficiency. Neurological disorders such as Gayet-Wernicke encephalopathy due to thiamine deficiency, or peripheral neuropathies may also be observed. Malabsorption of fat-soluble vitamins and other nutrients, especially if diagnosed after by-pass surgery, rarely cause clinical symptoms. However, some complications have been reported such as bone demineralization due to vitamin D deficiency, hair loss secondary to zinc deficiency or hemeralopia from vitamin A deficiency. A careful nutritional follow-up should be performed during pregnancy after obesity surgery, because possible deficiencies can affect the health of both the mother and child. In conclusion, increased awareness of the risk of deficiency and the systematic dosage of micronutrients are needed in the pre- and postoperative period in obese patients undergoing bariatric surgery. The case by case correction of these deficiencies is mandatory, and their systematic prevention should be evaluated.
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Affiliation(s)
- Vanessa Folope
- Unité de Nutrition et groupe ADEN EA3234, IFR23, CHU de Rouen, Rouen, France
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39
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Abstract
Nutritional deficiencies are already present in many morbidly obese patients before weight-loss surgery. Appropriate preoperative detection and correction is essential. The severity and pattern of deficiencies is dependent on the presence of preoperative uncorrected deficiency, the type of procedure performed varying with the degree of restriction or the length of bypassed small intestine, the modification of eating behavior, the development of complications, compliance with oral multivitamin and mineral supplementation, and compliance with follow-up. Rigorous control of fluids and electrolytes with establishment of adequate oral nutrition is important in the immediate postoperative period. Regular follow-up of the metabolic and nutritional status of the patient is essential, with life-long multivitamin and mineral supplementation.
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Affiliation(s)
- Olga N Tucker
- The Bariatric Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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Abstract
Obesity is a multifactorial disease of epidemic and global proportions that poses the most significant threat to the health of our younger generations. Those who are the most extremely affected bear the largest burden of health problems. In the US, extreme obesity affects approximately 9 million adults and 2 million children, and is associated with both immediate health problems and later health risk, including premature mortality. Present medical and behavioral interventions for extreme obesity in adults and children rarely result in the significant, durable weight loss necessary to improve health outcomes, prompting a search for more aggressive measures. Weight loss (bariatric) surgery has been advocated as an intervention for those with extreme obesity. In adults, bariatric surgery results in prolonged weight control and improvement in serious obesity comorbidities, namely type 2 diabetes, dyslipidemias, hypertension and obstructive sleep apnea syndrome. A surge in weight loss operations for adolescents has been observed recently, with a threefold increase in case volumes nationwide from 2000 to 2003. Current evidence suggests that after bariatric surgery, adolescents lose significant weight and serious obesity-related medical conditions and psychosocial status are improved. Thus it is reasonable to propose that bariatric surgery performed in the adolescent period may be more effective treatment for childhood-onset extreme obesity than delaying surgery for extremely obese youth until adulthood. This position has been echoed by a number of groups and an independent systematic review. Finally, it is conceivable that bariatric surgery performed in adulthood for childhood onset extreme obesity may not be as effective for comorbidity treatment as surgery performed earlier during adolescence. The purpose of this review is to examine the evidence, which supports early rather than later use of bariatric surgery in the treatment of extreme obesity, and to present this information in light of the medical and surgical risks of bariatric surgery.
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Affiliation(s)
- T H Inge
- Division of Pediatric and Thoracic Surgery, Comprehensive Weight Management Program, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA.
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Gaudet LM, MacKenzie J, Smith GN. Fat-soluble vitamin deficiency in pregnancy: a case report and review of abetalipoproteinemia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2006; 28:716-719. [PMID: 17022912 DOI: 10.1016/s1701-2163(16)32235-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Abetalipoproteinemia (ABL) is a metabolic disorder resulting in poor absorption of fat-soluble vitamins. CASE Two pregnancies in a woman with ABL are reported, contrasting outcomes with subtherapeutic and normal vitamin levels. CONCLUSION Fat-soluble vitamin levels in pregnancy are critical for many aspects of fetal development. This report details a congenital ophthalmologic finding that may be associated with vitamin A deficiency.
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Affiliation(s)
- Laura M Gaudet
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Kingston General Hospital, Queen's University, Kingston ON
| | - Jennifer MacKenzie
- Department of Medical Genetics, Kingston General Hospital, Queen's University, Kingston ON
| | - Graeme N Smith
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Kingston General Hospital, Queen's University, Kingston ON
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Smets KJ, Barlow T, Vanhaesebrouck P. Maternal vitamin A deficiency and neonatal microphthalmia: complications of biliopancreatic diversion? Eur J Pediatr 2006; 165:502-4. [PMID: 16718478 DOI: 10.1007/s00431-006-0120-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 02/23/2006] [Indexed: 02/05/2023]
Abstract
Biliopancreatic diversion (BPD) for morbid obesity carries a serious risk of nutritional deficiencies that might impair embryogenesis. Consequently, attention should be given to the potential of risk to the fetus of BPD in women of childbearing age. We present the case of a pregnant woman who had undergone BPD 8 years previously, with documented vitamin A deficiency, who gave birth to a child with bilateral microphthalmia. Infectious and genetic causes of microphthalmia were excluded. A search of the literature revealed that vitamin A deficiency may cause a disruption of ocular development. We conclude that nutritional deficiencies may cause a spectrum of fetal malformations. As the effect of BPD relies on malabsorption, fetal risk should be considered before BPD is offered to morbid obese women of childbearing age.
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Affiliation(s)
- Koenraad Jan Smets
- Neonatal Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, Gent, 9000, Belgium.
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Abstract
PURPOSE OF REVIEW Bariatric surgery is being increasingly used to help treat morbidly obese adults and adolescents. As a greater percentage of this population faces a lifetime of living with surgically altered gastrointestinal anatomy and physiology, increased awareness of the nutritional consequences is critical for all health care practitioners, as many of these patients may be lost to follow-up and can present with significant nutritional complications years after surgery. RECENT FINDINGS Nutritional deficiencies can occur after bariatric surgery, although to a lesser degree after restrictive procedures. Risk may increase over time, perhaps due to poor compliance with supplementation, continued inadequate intake and/or ongoing malabsorption. Adolescent patients may be at greater risk due to poor compliance and longer life span. Nutritional monitoring and supplementation among bariatric programs has been widely variable and few prospective studies of outcomes exist. SUMMARY Bariatric surgery can carry significant risk of nutritional complications. Compliance with dietary recommendations should be monitored and encouraged, with annual screening for selected deficiencies. Prospective longitudinal research is needed to identify the true prevalence and significance of nutritional deficiency in these patients and to determine optimum dietary recommendations.
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Affiliation(s)
- Stavra A Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Ohio 45229-3039, USA.
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Cools M, Duval ELIM, Jespers A. Adverse neonatal outcome after maternal biliopancreatic diversion operation: report of nine cases. Eur J Pediatr 2006; 165:199-202. [PMID: 16416132 DOI: 10.1007/s00431-005-0056-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Accepted: 11/16/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Martine Cools
- Neonatal Intensive Care Unit, Queen Paola Children's hospital, Antwerp, Belgium
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Biesalski HK, Nohr D. New aspects in vitamin a metabolism: the role of retinyl esters as systemic and local sources for retinol in mucous epithelia. J Nutr 2004; 134:3453S-3457S. [PMID: 15570053 DOI: 10.1093/jn/134.12.3453s] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Vitamin A and its active metabolites are important for growth and differentiation of a variety of cells, mainly in mucosa-associated epithelia, where they exhibit a wide spectrum of activities. Vitamin A, stored as retinyl esters (REs), is delivered from liver stores into the bloodstream as retinol bound to retinol binding protein. This process is regulated homeostatically, ending up in a more or less constant plasma retinol level. In situations of a high vitamin A demand (e.g., inflammation, diseases, prenatal period), this supply can be insufficient because of delayed production of retinol binding protein, leading to local deficiencies and impairment of structure and function in the respective tissues. This delay may be overcome by cellular RE stores. Several cell types, including buccal mucosa cells, can take up RE. Retinyl palmitate is taken up when it is applied topically to either metaplastically mutated rat vaginal epithelium (as a gel) or to human meta- and dysplastic bronchial epithelia (via inhalation) that have a vitamin A deficiency. In rats and humans, the modified epithelia can be normalized, at least in part. In conclusion, topically applied retinyl esters may be a promising therapy for local retinol deficiencies and may reverse the morphological alterations of the epithelium in tissues that are vitamin A deficient.
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Affiliation(s)
- Hans K Biesalski
- Department of Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, FRG.
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Abstract
PURPOSE OF REVIEW The number of adolescent and adult patients submitting to bariatric surgery is increasing rapidly around the world. This review describes the literature published in the last few years concerning nutritional deficiencies after bariatric surgery as well as their etiology, incidence, treatment and prevention. RECENT FINDINGS Although bariatric surgery was first introduced in the 1950s, safe and successful surgical management has progressed over the last two decades and longer post-surgical follow-up data are now available. Most of the patients undergoing malabsorptive procedures will develop some nutritional deficiency, justifying mineral and multivitamin supplementation to all postoperatively. Nutrient deficiency is proportional to the length of absorptive area and to the percentage of weight loss. Low levels of iron, vitamin B12, vitamin D and calcium are predominant after Roux-en-Y gastric bypass. Protein and fat-soluble vitamin deficiencies are mainly detected after biliopancreatic diversion. Thiamine deficiency is common in patients with frequent vomiting. As the incidence of these deficiencies progresses with time, the patients should be monitored frequently and regularly to prevent malnutrition. SUMMARY Nutritional deficiencies can be prevented if a multidisciplinary team regularly assists the patient. Malnutrition is generally reverted with nutrient supplementation, once it is promptly diagnosed. Especial attention should be given to adolescents, mainly girls at reproductive age who have a substantial risk of developing iron deficiency. Future studies are necessary to detect nutrient abnormalities after new procedures and to evaluate the safety of bariatric surgery in younger obese patients.
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Affiliation(s)
- Jacqueline I Alvarez-Leite
- Biochemistry and Immunology Department, Institute of Biological Sciences and Alfa Institute of Gastroenterology, Clinics Hospital, Medical School, Federal University of Minas Gerais, Brazil.
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Russo EB, Merzouki A, Mesa JM, Frey KA, Bach PJ. Cannabis improves night vision: a case study of dark adaptometry and scotopic sensitivity in kif smokers of the Rif mountains of northern Morocco. JOURNAL OF ETHNOPHARMACOLOGY 2004; 93:99-104. [PMID: 15182912 DOI: 10.1016/j.jep.2004.03.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2003] [Revised: 03/01/2004] [Accepted: 03/18/2004] [Indexed: 05/24/2023]
Abstract
Previous reports have documented an improvement in night vision among Jamaican fishermen after ingestion of a crude tincture of herbal cannabis, while two members of this group noted that Moroccan fishermen and mountain dwellers observe an analogous improvement after smoking kif, sifted Cannabis sativa mixed with tobacco (Nicotiana rustica). Field-testing of night vision has become possible with a portable device, the LKC Technologies Scotopic Sensitivity Tester-1 (SST-1). This study examines the results of double-blinded graduated THC administration 0-20 mg (as Marinol) versus placebo in one subject on measures of dark adaptometry and scotopic sensitivity. Analogous field studies were performed in Morocco with the SST-1 in three subjects before and after smoking kif. In both test situations, improvements in night vision measures were noted after THC or cannabis. It is believed that this effect is dose-dependent and cannabinoid-mediated at the retinal level. Further testing may assess possible clinical application of these results in retinitis pigmentosa or other conditions.
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Perrotta S, Nobili B, Rossi F, Di Pinto D, Cucciolla V, Borriello A, Oliva A, Della Ragione F. Vitamin A and infancy. Biochemical, functional, and clinical aspects. VITAMINS AND HORMONES 2003; 66:457-591. [PMID: 12852263 DOI: 10.1016/s0083-6729(03)01013-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Vitamin A is a very intriguing natural compound. The molecule not only has a complex array of physiological functions, but also represents the precursor of promising and powerful new pharmacological agents. Although several aspects of human retinol metabolism, including absorption and tissue delivery, have been clarified, the type and amounts of vitamin A derivatives that are intracellularly produced remain quite elusive. In addition, their precise function and targets still need to be identified. Retinoic acids, undoubtedly, play a major role in explaining activities of retinol, but, recently, a large number of physiological functions have been attributed to different retinoids and to vitamin A itself. One of the primary roles this vitamin plays is in embryogenesis. Almost all steps in organogenesis are controlled by retinoic acids, thus suggesting that retinol is necessary for proper development of embryonic tissues. These considerations point to the dramatic importance of a sufficient intake of vitamin A and explain the consequences if intake of retinol is deficient. However, hypervitaminosis A also has a number of remarkable negative consequences, which, in same cases, could be fatal. Thus, the use of large doses of retinol in the treatment of some human diseases and the use of megavitamin therapy for certain chronic disorders as well as the growing tendency toward vitamin faddism should alert physicians to the possibility of vitamin overdose.
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Affiliation(s)
- Silverio Perrotta
- Department of Pediatric, Medical School, Second University of Naples, Naples, Italy
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