Pregnancy after bariatric surgery presents unique nutritional challenges and considerations. This article provides a comprehensive overview of bariatric pregnancy, focusing on dietary guidelines to support both maternal and fetal health. It incorporates a range of expert opinions and evidence-based recommendations to help guide women through this special time.
Understanding Bariatric Pregnancy
A bariatric pregnancy occurs when a woman becomes pregnant after undergoing weight loss surgery to treat obesity. The surgery alters the body's anatomy, affecting nutrient absorption and metabolism. While bariatric surgery can improve fertility and maternal outcomes for obese women, it also makes pregnancy high-risk, necessitating careful attention to dietary and nutritional factors. How you eat during your pregnancy after bariatric surgery can make all the difference as you improve nutritional intake and avoid pregnancy issues.
It is generally advised to delay pregnancy for 12-24 months after bariatric surgery to allow for weight stabilization and reduce the risk of intrauterine growth retardation.
Lifelong Lifestyle Changes
Starting today, you agree to:
- Eat 3 meals a day.
- Eat protein and a carbohydrate choice at each meal.
- Eat your protein first.
- Take 30 minutes to eat your meal.
- Chew your food to a pureed/mush consistency. This takes 20 to 30 chews.
- Eat nutrient-dense foods such as vegetables, whole grains, fruits, and lean meats.
- Do not eat calorie-dense foods such as chips, cookies, crackers, ice cream, fried food, candy, hot dogs, brats, and bologna.
- Do not eat non-nutrient-dense foods such as pretzels, rice cakes, and animal crackers.
- Eat 3 milk snacks each day.
- Do not drink carbonated fluids such as pop, juice, or alcohol. Carbonation can cause stomach pain. These drinks have extra calories and sugar that is not needed.
- Drink 6 or more cups of plain water a day. You may drink 8oz of unsweetened coffee or tea per day. Do not drink anything with citric acid.
- Do not drink fluids 30 minutes before meals, with meals, or for 30 minutes after meals.
- Do not use tobacco or nicotine products. It slows down healing and can lead to complications.
- Exercise 30 minutes or more a day.
- Keep detailed food and activity records (bubble sheets). Bring them to each dietitian appointment.
- Do not use straws. Air bubbles form in your new pouch and can cause pain.
- The first 3 months after surgery, do not eat acidic or citrus foods such as tomatoes, lemon, orange, or lime.
Dietary Information
Learning how and what to eat before, during, and after bariatric surgery is a large part of your patient education. You must follow these guidelines from your surgeon and dietitian to be sure you get proper nutrition and do not have complications. You will have the best weight loss and surgery outcomes if you closely follow the nutrition, vitamin, and mineral supplementation and exercise recommendations.
Read also: Diet Before Bariatric Surgery
Bariatric Diet Progression
| When to start | Phase of diet |
|---|---|
| Today | Low-calorie general diet |
| 10 days before surgery | Pre-surgery blended liquid diet |
| Day of surgery | No food or drink |
| Day 1 (in the hospital) | Clear liquid diet |
| Days 2 to 14 (2 weeks) | Full liquid diet |
| Days 15 to 30 (until 1 month visit) | Pureed diet (very smooth) |
| Days 31 to 60 (after 1 month visit) | Soft diet |
| Days 61 to forever | General diet |
Meeting Nutritional Needs
During bariatric pregnancy, the concept of "eating for two" requires a nuanced approach. The surgical changes in the digestive system can impact nutrient absorption, highlighting the significance of a well-balanced and nutrient-rich diet.
Protein
Protein plays a central role, supporting tissue growth, cellular repair, and the development of vital organs in the growing fetus. A minimum intake of 60 g of protein per day is universally recommended but tailored to the individual patient. Food and fluid fortification techniques may help increase the protein intake of the usual diet.
Iron
Ensuring sufficient iron intake is crucial to prevent anemia and support the increased blood volume characteristic of pregnancy. Iron intake is especially crucial following a Roux-en-y gastric bypass surgery. Current guidelines recommend that patients undergoing gastric bypass, sleeve gastrectomy and biliopancreatic diversion/duodenal switch operations should be supplemented with 45-60 mg elemental iron. This should increase to 100 mg of elemental iron per day for menstruating women. Additional supplementation with vitamin C to aid absorption should be considered in those with persistently low iron levels. Monitoring of iron status should be undertaken at regular intervals.
Calcium
Calcium is vital for strong bones and teeth, contributing to the baby's skeletal development and helping maintain the mother's bone health. A calcium intake of 1500 mg daily in women who have had bariatric surgery is recommended. During lactation, 300-400 milligrams of calcium are lost into breast milk per day.
Micronutrients
Folic acid is a must to prevent fetal neural tube defects. Vitamins such as B12 and vitamin D are also crucial, each playing a role in cellular function, bone health, and overall immune support. Pre-conception supplementation with 400 micrograms per day of folic acid and continuing until the 12th week of pregnancy is recommended . This increases to 5 mg in women at higher risk, including those with obesity and/or diabetes and those with a history of prior pregnancies complicated by neural tube defects. Women who have undergone bariatric surgery should be deemed as high-risk.
Read also: Bariatric Surgery Outcomes
Bariatric surgery patients are commonly at risk for deficiencies of water-soluble vitamins B12, B1, folate and C; fat-soluble vitamins A, D, E and K; and the minerals iron, zinc, selenium, calcium, magnesium and copper. Add these to your diet with a multi-dose, high-quality prenatal, and you'll be taking care of a significant portion of your micronutrient needs after bariatric surgery.
Managing Weight Gain
Balancing healthy weight gain while ensuring proper nourishment requires careful consideration. A well-structured diet can facilitate weight management and minimize the risk of complications, all while fostering the optimal growth of the developing baby.
Strategic portion control and mindful eating practices become allies in managing weight gain. Pregnant women should avoid any further weight loss during pregnancy, instead focusing on a balanced, varied dietary intake. Weight gain during pregnancy of 6 kg in those with a BMI > 25 kg/m2 should be expected, and no more than 12 kg in women of a healthy BMI .
Blood Sugar Control
To promote blood sugar control, a diet that supports pregnancy after bariatric surgery must be based on whole foods. Right off the bat, foods that need to be in the diet will include meats, poultry, and eggs. Carbohydrates may still be in the diet in limited amounts to avoid sudden spikes in blood sugar. For carbohydrate sources, complex varieties like vegetables are preferable since they promote steady glucose release and prevent cravings.
Hydration
Adequate hydration is crucial for any pregnancy, and bariatric pregnancy is no exception. Sipping water throughout the day ensures proper hydration, aids digestion, and supports overall well-being. Proper hydration is essential for maintaining amniotic fluid levels, supporting the placenta, and ensuring the optimal function of bodily systems. It also helps alleviate common pregnancy discomforts such as constipation and swelling. While water is the primary source of hydration, herbal teas, clear soups, and water-rich fruits can also contribute to your fluid intake.
Read also: Is Bariatric Surgery Right for You?
Addressing Micronutrient Deficiencies
One of the most critical roles of bariatric pregnancy nutrition is addressing vitamin and mineral deficiencies. By addressing any gaps in your micronutrient intake, you prevent a range of complications, from poor fetal growth to impaired maternal recovery.
Getting all your nutrients from food may not always suffice given the digestive and metabolic changes resulting from bariatric surgery. This is where supplementation comes in.
Low-Carb, High-Protein Diets
One eating approach outshines other kinds of dietary advice: low-carb, high-protein diets. This approach to eating ensures the steady availability of micro and macronutrients for pregnant women.
Steadier Blood Sugar Levels
The focus on reducing rapidly digestible carbohydrates helps prevent the spikes and crashes in blood sugar that can be particularly concerning for those who have undergone bariatric surgery.
Satiety and Sustenance
Protein-rich foods have a unique ability to induce a feeling of fullness that lasts, supporting appetite control and potentially aiding in weight management. This aspect is especially valuable for women who have undergone bariatric surgery, as their modified digestive system often requires smaller, more frequent meals that are nutrient-dense.
Bariatric Surgery Full Liquid Diet
You will be on a full liquid diet days 2 to 14 after your surgery. Full liquids are foods that are normally liquid and foods that turn into liquid when they are at room temperature.
You need to:
- Drink six 8 oz glasses of water each day. Take 5 to 15 minutes to drink 1 oz.
- Do not wait 30 minutes before or after meal to drink fluids. Sip throughout the day.
- Stop eating when you are full!
- Start taking vitamin and mineral supplements after your 1 week follow-up visit, as ordered.
- Follow all of the "Lifestyle Changes."
Double Milk Snack Choices - choose 3 per day
- 1 cup fat free Fairlife milk
- 5 to 6 oz Greek yogurt (100 kcal or less)
- 1 cup fat free Fairlife or regular skim milk + 2 tbsp Peanut Butter powder
- 1/2 cup Cottage cheese (fat free or 1%)
- 1 cup skim milk + 1/3 cup non-fat dry milk powder
- 1 cup skim milk + Carnation Instant Breakfast (Light Start or No-Sugar-Added)
- 1/2 protein shake (see table on following page for choices)
*can flavor milks with Peanut Butter Powder, sugar-free chocolate syrup or sugar-free hot coco mix
Meal Portion Size:
- Protein: 1/4 to 1/3 cup or 2 to 3 oz
- Carbohydrate: 1/4 cup
Full liquid food ideas:
- Sugar- free pudding (make with Fairlife or add collagen protein powder or non-fat dry milk powder for extra protein)
- Cream soups (celery, mushroom, chicken, broccoli, ect.)
- Homemade blended liquid soups (ex. Butternut squash soup, Carrot ginger soup)
- Sugar-free popsicle (limit 1 per day)
- Lite yogurt (no fruit chunks)
- Other blended strained soups
Recipes
Roasted carrot ginger soup
- 1 1.2 pounds (lbs) carrots, peeled and halves lengthwise
- 1 lb parsnips, peeled and quartered lengthwise
- 1 onion, diced
- 1 teaspoon (tsp) ginger
- 2 cups dry milk
- 8 cups chicken broth
- Pinch cayenne pepper
- Brown sugar
Directions:
- Preheat over to 350 degrees F.
- Put the carrots, parsnips, onion, and ginger in a shallow roasting pan.
- Sprinkle with brown sugar.
- Pour 2 cups of broth into the pan and cover well with foil.
- Bake until the vegetables are very tender (about 2 hours).
- Put the baked vegetables and broth to a large pot.
- Add the last 6 cups of broth, salt, and cayenne pepper.
- Bring to a boil, lower the heat, and let it simmer partially covered for 10 minutes.
- Puree the soup in a blender or food processor, adding 2 cups nonfat dry milk.
- Put the soup back into the pot, adjust seasonings, and heat through.
Cream Soup
- 1/3 cup nonfat dry milk powder
- 1 tsp chicken or beef bouillon
Directions:
Mix dry ingredients and add hot water to equal 1 cup.
Butternut Squash Soup
- 1 tablespoon (Tbsp) vegetable oil
- 1 each butternut squash
- 2 cup dry milk
- 3 cups low sodium chicken broth
- 2 tsp fresh ginger, grated
- 1 each medium sweet potato
- 2 each large golden delicious apples
- 1/2 cup skim milk
- 2 tsp cumin
- 1 each medium white onion
- 2 cloves garlic
- 1/2 cup fat free buttermilk
- Pinch pepper
Directions:
- Peel potato, onion, apple, and squash. Cut it into 1/4 inch chunks.
- Heat 1 Tbsp oil over medium heat in a large saucepan or stock pot. Stir in onion and garlic until tender.
- Add broth, potato, apple, squash, and seasoning. Stir well.
- Lower the heat to medium-low and let it simmer until the vegetables are tender (about 20 minutes).
- Puree soup in a blender until nicely pureed. While pureeing add 1/2 cup of milk, 1/2 cup of buttermilk, and 1 cup dry milk.
- Serve hot or chilled.
Bariatric Surgery Pureed Diet
You will be on a pureed diet days 15 to 30 after your surgery.
Bariatric Surgery Soft Diet
You will be on a soft diet days 31 to 60 after your surgery. You will start this diet after your 1 month follow-up visit.
You need to:
- Chew foods to a pureed consistency (chew 20 to 30 times before swallowing).
- Slowly add soft foods to your meals and snacks.
- Take 30 minutes to eat.
- Eat 3 milk snacks per day and 3 soft food meals.
- Drink six 8 oz glasses of water each day, working up to eight 8oz glasses.
- Stop eating when you are full!
- Take vitamin and mineral supplements as ordered.
- Start doing strength-building exercise in your daily routine, such as strength and aerobics for 60 minutes each day.
Milk Snack Choices - choose 3 per day
- 1 cup skim Fairlife milk
- 5 to 6 oz Greek Yogurt (100 kcal or less)
- 1 cup skim milk
- 1/2 cup Cottage cheese (fat free or 1%)
- 1 lite mozzarella string cheese stick
- 1 cup unsweetened soy milk (or high protein pant-based milk)
- 1/2 cup Fat Free Chocolate Milk (mixed with 1/2 cup skim white milk)
- 1/2 protein shake (see previous page for choices)
*Can flavor milks with Peanut Butter Powder, sugar-free chocolate syrup or sugar-free hot coco mix
Meal Portion Size:
- Protein: 1/4 to 1/3 cup or 2 to 3 oz
- Vegetable: 1 to 2 bites
- Carbohydrate (fruit & starches): 1 to 2 bites
Soft Food (Looking for crockpot tender):
- Chicken
- Sweet potato
- Banana
- Ground turkey or pork
- Carrots
- Oatmeal
- 90% lean ground beef
- Cauliflower
- Potato
- Salmon, Tilapia, Tuna
- Green Beans
- Cream of Wheat
- Eggs
- Black beans
- Peaches
- Refried Beans
- Broccoli
- Brown Rice
* Not all foods listed, see Choose Your Foods book for more food choices.
Soft Food Menu Items:
| Breakfast | Lunch | Dinner |
|---|---|---|
| 1/2 slice of toast with low sugar fruit spread | 2 to 3 ounces shredded chicken1/4 cup green beans | 2 to 3 ounces salmon 1/4 cup mixed vegetables |
| 2 scrambled eggs1 to 2 bites of fruit | 1 to 2 ounces ground turkey1-ounce light cheese1/4 cup black beans | 2 to 3 ounces baked fish 1/4 cup cooked carrots1-2 bites of fruit |
| 1/4 cup turkey sausage1-ounce light cheese1/2 tortilla (6 inch) |
Bariatric Surgery General Diet
You will be on a general bariatric diet for the rest of your life starting day 61 after your surgery.
You need to:
- Chew food to pureed consistency (chew 20 to 30 times before swallowing).
- Eat lean foods, such as baked, broiled, grilled, or steamed foods.
- Drink eight 8-oz glasses of water each day.
- Take vitamin and mineral supplements as ordered.
- Keep doing strength and aerobic exercise for 60 minutes or more each day.
Milk Snack Choices - choose 3 per day
- 1 cup skim Fairlife milk
- 5 to 6 oz Greek yogurt (100 kcal or less)
- 1 cup skim milk
- 1/2 cup Cottage cheese (fat free or 1%)
- 1 lite mozzarella string cheese stick
- 1 cup unsweetened soy milk (or high protein plant-based milk)
- 1/2 cup Fat Free Chocolate milk (mixed with 1/2 cup skim white milk)
- 1/2 protein shake (see previous page for options)
* can flavor milk with Peanut Butter Powder.
What Foods To Add to Your Diet
Choosing the right foods after bariatric surgery can make all the difference in your pregnancy outcome and maternal nutritional status. When selecting foods, go for whole nutrient-dense ones. These will help keep your weight close to your pre-pregnancy weight, hasten your recovery after delivery, and improve neonatal outcomes.
Animal Protein Sources
With enough protein in your diet, you'll avoid most pregnancy complications and ensure that your body gets what it needs to rebuild tissues and cells - both yours and the baby's. Best protein sources include any animal-based meats. These foods contain the necessary amino acids for tissue repair, immune function, and the healthy growth of your developing baby. Also, the inclusion of protein-rich foods in every meal creates fullness and satiety, an invaluable asset in managing appetite and supporting weight management.
Vegetables
Vegetables are packed with fiber to keep unhealthy weight gain at bay. They're also powerhouse sources for micronutrients like folate and iron. Vegetables also abound with iron, which is a must for healthy red blood cell formation during pregnancy, though not absorbed as well as from animal sources.
Vegetables - unlike macronutrient sources like carbs and fats - have a remarkable nutrient-to-calorie ratio. This means that they add all the necessary nutrients without all the calories. This makes vegetables superior to other foods in terms of avoiding maternal vitamin deficiencies and unhealthy weight gain. Most importantly, they're an excellent way to get your vitamins in if you can't eat much due to your surgery.
You can cover most bases by adding the following:
- Bell pepper
- Green leafy vegetables
- Cruciferous vegetables like broccoli and cauliflower
- Vitamin A-rich vegetables like carrots
When you're incorporating vegetables into your diet, variety is key.
Healthy Fats
Fats are essential to hormonal regulation and the health of vital organs like the brain. When selecting fats, avoid seed oils and trans fat.
Common Nutrient Deficiencies
Common nutrient deficiencies following bariatric surgery can be exacerbated by pregnancy symptoms such as morning sickness or hyperemesis, gastro-esophageal reflux, abdominal bloating and pressure symptoms. Compliance may also be a concern, with studies reporting poor adherence with nutritional supplementation post-operatively .
Iron Deficiency
Iron deficiency is the most commonly encountered deficiency following bariatric surgery, occurring in nearly one half of patients, particularly after Roux-en-Y gastric bypass or biliopancreatic diversion surgeries . Mechanisms for iron deficiency post-bariatric surgery include reduced gastric pH, limited intestinal absorption, avoidance of iron-rich foods, reduced gastric acid secretion, use of proton pump inhibitors, and the exclusion of the duodenum and jejunum (primary sites of absorption). Women of childbearing age are most at risk due to menstrual losses. There is evidence that maternal iron deficiency leads to an increased risk of pre-term delivery and subsequent low birth weight .
Vitamin B12 Deficiency
Vitamin B12 (cobalamin) functions as an essential co-enzyme in several important enzyme-catalyzed reactions. Deficiency of vitamin B12 can lead to megaloblastic anemia and potentially irreversible neurological damage and fetal neural tube defects. Vitamin B12 deficiency is common following bariatric surgery due to reduced availability of intrinsic factor and malabsorption. Patients undergoing procedures which exclude the greater curvature of the stomach, such as gastric bypass, sleeve gastrectomy and biliopancreatic diversion/duodenal switch are at particular risk . In one study, deficiency was reported in over 50% of pregnancies occurring post-bariatric surgery .
Vitamin A Deficiency
The general pregnant population is usually advised to avoid vitamin A supplementation due to the risk of fetal malformation with retinol isoforms . However, as a fat-soluble vitamin, vitamin A deficiency can be encountered due to malabsorption following bariatric surgery. Maternal vitamin A deficiency has been shown to cause night blindness and is associated with increased maternal mortality and pre-term birth .
Important Considerations
- Contraception and preconception counseling: Should be provided for all women of reproductive age who are undergoing bariatric surgery.
- Wait period: After bariatric surgery, a woman should wait 12 to 24 months before conceiving.
- Expert care: It’s important to work with experts who understand the effect of bariatric surgery on pregnancy.
tags: #bariatric #pregnancy #diet #guidelines