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Post bariatric nutrition

Watch Helen and Kathyrn discuss the topic of pregnancy in women who are post bariatric surgery.
HELEN TRUBY: We’ve almost seen an emergence of a new type of pregnancy in women who are post-bariatric surgery. What sort of challenges do these present?
KATHRYN HART: Yeah, you’re right. This is not something we’ve ever had to deal with, you know, ten, twenty years ago. But because A, the rates of surgery have been going up, and also the people having that surgery’s really shifted. In recent years, we’re seeing much more younger women and women generally having the surgery, which therefore means that they are still of reproductive age. So this is a real emerging issue that we’re having to deal with. And I guess it comes down a lot to the type of surgery that they’ve had. So again, the types of surgery have changed over time. Banding seems to be less popular.
And the malabsorptive and more invasive surgeries are becoming more popular because they have better weight loss results. But clearly there’s other implications in terms of micronutrient quality and absorption as well.
HELEN TRUBY: But in terms of their micronutrient requirements, are there any specific ones that are particularly at risk?
KATHRYN HART: We don’t have a lot of specific guidance, if I’m honest, in terms of what we should be advising for women who’ve had surgery and then are going to become pregnant. But what we can do is obviously be pragmatic, and combine what we know about post-surgical recommendations, which are quite well defined now, and what we know about normal pregnancy requirements. So it does have to be very much individualised. And really, it’s about very close monitoring. So the sooner we know that someone wants to become pregnant, the better.
HELEN TRUBY: So this would be a group, potentially, that would be candidates for micronutrient supplementations in the form of tablets or capsules or whatever, which is usually something we tend to avoid, don’t we, in pregnancies, where we think the diet quality is enough. What sort of micronutrient supplementation would be suggested?
KATHRYN HART: So anyone post-bariatric surgery will be put on to a very specific supplementation regimen anyway. And that would be a multiple micronutrient supplement, so really across the board aiming to meet their requirements on a daily basis. And they will need to take that for quite long periods of time and sometimes for the rest of their life. So actually, when it comes to pregnancy, we don’t need to change that massively. But there are obviously some tweaks that we need to make. So we need to look at the form that the vitamin A is in to make sure that that’s safe for pregnancy.
And we would certainly want to give them additional folic acid in the preconception period ideally and obviously into the first trimester. Other than that, it’s very much a case of monitoring. So you know, we’re going to be very conscious of their iron intake and their vitamin D. But the post-surgical patients will be advised to take those things routinely anyway. So it is a case of just monitoring for things that we know are particularly at risk during pregnancy.
HELEN TRUBY: So in terms of the type of surgery that someone’s undertaken, and we’ve said banding is not so popular now, but the surgeries that cause really long-term malabsorption or are as restrictive as well as malabsorbtive, those presumably women would be at quite high risk?
KATHRYN HART: Yeah, absolutely. And we have to acknowledge that. And so it is really important that they are engaging with their healthcare professionals and following the advice they’ve been given post surgery anyway, because, of course, not everybody continues to do that as time passes. So that’s really important as a baseline. And then, yeah, on top of that, adding in some extra supplementation and certainly some more frequent monitoring of things like B12 and folate and iron, just to check. But it is really done on an individual basis. It’s very hard to set specific pregnancy recommendations for these women. We just know that those are things that can dip down.
And particularly iron, actually, is one of the ones that longer post surgery seems to be more of an issue. So not in the immediate post-surgical period, but certainly women two or three years later can really have issues with anaemia.
HELEN TRUBY: So obviously it would be ideal for women post-bariatric surgery to get down to their ideal weight before planning a pregnancy. But we know from the literature that often doesn’t happen. Is there particular guidance that we need to think about for women who are of childbearing age after they have bariatric surgery?
KATHRYN HART: Yeah. I mean, in an ideal world, you’re correct, because we know fertility is restored very quickly. And actually it’s not dependent on weight loss. I think that’s a misconception that they need to lose the weight before the fertility returns. There’s clearly other mechanisms at play because the fertility can return very quickly. And obviously these are women who may have suffered from infertility for their entire adult life. So often despite perhaps being told about this before the surgery, they’re not expecting it. And so they can get pregnant very quickly.
So ideally, we need to be educating and informing them before they even have the surgery, and not waiting for them to necessarily make a decision about conceiving because by that point, they may already have conceived.
HELEN TRUBY: And really a whole new area of dietary advice that’s required, again, to be tailored to that particular lady and the particular surgical procedure, in particular in terms of micronutrient requirements as well.
KATHRYN HART: Yeah. And it’s almost a new speciality. And it’s who takes that on because they will be under the surgical teams clearly for their surgery, and the follow up for several years post surgery, but within that period could obviously become pregnant and then will be managed by an obstetric team. And so it’s about bringing all those specialists together, with the dietitians, to really come up with some good robust evidence to help the mother, but also the baby, because we know that what happens during pregnancy has implications for the infant long into adulthood for themselves as well.
HELEN TRUBY: Yes, incredibly important area. Thank you.

Watch Helen and Kathyrn discuss the topic of pregnancy in women who are post bariatric surgery and the associated challenges it brings to providing pregnancy and nutrition advice to women.

Talking point

As you watch the video, reflect on your professional practice and the advice you’ve given to women who are post bariatric surgery.

Note the challenges you encountered and if they were similar or the same as those mentioned by Helen and Kathyrn, and then within the Comments briefly describe the solution or advice you gave to your patient.

If this area is new to you, consider briefly describing a solution or advice that you’d give to a patient in a situation similar to that described by Helen and Kathryn.

Also consider sharing how you see yourself using this information about post bariatric nutrition in your professional practice – how will you now advise your patients?

Don’t forget to consider reading and commenting on contributions made by other learners. You can also ‘Like’ comments or follow other learners throughout the course.

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Food as Medicine: Fertility and Pregnancy

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