obesity, gastric bypass, &...

Obesity, Gastric Bypass, &

Breastfeeding Erin Garcia, MAS, RD, IBCLC

Disclosures

Objectives

Be able to identify at least1 implication of

maternal obesity on breastfeeding

Be able to identify at least1implication of

weight loss surgery on breastfeeding

Be able to identify at least 2 ideas to help

support breastfeeding mothers who are

obese or have gone through weight loss

surgery (or both)

Agenda

Obesity ◦ Definition & Background

◦ Hormonally

◦ Physically

Types of Weight Loss Surgeries ◦ Definition and Types

◦ Nutritional Implications

◦ Physical Implications

Other Factors

Group Activity

Support and Advice

Questions

Obesity

Obesity means having too much body fat. It is different from being overweight,

which means weighing too much. The weight

may come from muscle, bone, fat, and/or

body water. Both terms mean that a person's

weight is greater than what's considered

healthy for his or her height. http://www.nlm.nih.gov/medlineplus/obesity.html

Obesity

Body Mass Index (BMI) is a number

calculated from a person's weight and

height. BMI is a fairly reliable indicator

of body fatness for most people.

Formula: weight (kg) / [height (m)]2

http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html

Obesity

http://www.nhlbi.nih.gov/health/health-topics/topics/obe/diagnosis.html

BMI Weight Status Weight Range Height

Below 18.5 Underweight 124 # or less

5’9”

18.5-24.9 Normal 125-168 #

25.0-29.9 Overweight 169-202 #

30.0-39.9 Obese 203-270 #

40.0 & above Extreme Obesity 271 # and above

Obesity

http://usatoday30.usatoday.com/sports/basketball/nba/2011-06-01-shaquilleoneal_N.htm

2000

Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011

*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

CA

MT

ID

NV

UT

AZ NM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

IL OH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

PR GUAM

NH

MA

RI

CT

NJ

DE

MD

DC

http://www.cdc.gov/obesity/data/prevalence-maps.html

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%



CA

MT

ID

NV

UT

AZ NM

WY

WA

OR

CO

NE

ND

SD

TX

OK

KS

IA

MN

AR

MO

LA

MI

IN

KY

IL OH

TN

MS AL

WI

PA

WV

SC

VA

NC

GA

FL

NY

VT

ME

HI

AK

NH

MA

RI

CT

NJ

DE

MD

DC

PR GUAM


Obesity

Obesity

http://www.recordnet.com/apps/pbcs.dll/article?AID=/20100305/A_NEWS/3050320/-1/A_NEWS0803

http://businessjournal.gallup.com/content/145778/cost-obesity-cities.aspx http://

Obesity

http://www.cdph.ca.gov/data/surveys/MIHA/MIHASnapshots/SnapshotRegSanJoaquinValley2011.pdf

Obesity

http://www.cdph.ca.gov/data/surveys/MIHA/MIHASnapshots/SnapshotRegSanJoaquinValley2012.pdf

http://www.cdph.ca.gov/data/surveys/MIHA/Pages/ComparisonMaps.aspx

Obesity

Obesity

Obesity

Hormonally

◦ Prolactin

◦ Insulin

Obesity

Prolactin Response

◦ Lower prolactin response to suckling

48 hours & 7 days pp

◦ Important in the first week

No difference in progesterone concentrations

◦ Bigger babies

Larger babies=decreased prolactin

response to suckling

Obesity

Insulin

◦ 28-44% higher concentrations

◦ At the time insignificant, but is it?

2013 Study & Insulin’s role

◦ Women with lower insulin sensitivity

◦ Over expression to insulin resistance

Obesity

Physical Considerations

◦ Larger (heavy) breasts

◦ Larger & flatter nipples

◦ Inadequate mammary development?

http://girldujour.wordpress.com/tag/breast-obsession/

Obesity

Obesity

Whole-mount analysis of mammary

glands on day 14 of pregnancy in lean (A)

and obese (B) mice. Scale bar represents

1 mm.

Flint et.al. 2005 AJP-Endocrinol Metab, 288: E1179-E1187

Weight Loss Surgery

Weight Loss Surgery

Types

◦ Roux-en-Y

◦ Lap-band

◦ Gastric Sleeve or resection

◦ Biliopancreatic diversion with duodenal

switch

Weight Loss Surgery

Roux-en-Y

◦ Both restrictive

and

malabsorption

http://www.aspirus.org/media/Roux-en-Y-Gastric-Bypass%20Diagram.pdf

Weight Loss Surgery

Gastric Sleeve

◦ Restrictive

http://www.lapbandinformation.com/surgery_gastricsleeve.shtml

Weight Loss Surgery

Lap Band

◦ Restrictive

◦ Adjustable

http://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm248133.htm

Weight Loss Surgery Roux-en-Y Gastric Sleeve Lap Band

Pros: Highest expected

weight loss.

Modulation of hunger

hormones.

Strongest potential for

improving T2DM.

Pros: Modulation of gut

hormones.

Less complicated

surgery.

Pros: Adjustments can

be made if losing weight

too slowly or not

quickly enough.

Potential

Complications:

Dumping Syndrome.

Malabsorption.

Micronutrient

Deficiencies.

Risk of Ulcers (esp. with

NSAIDS/smoking).

Anastomotic Ulcers.

Potential

Complications:

Gastro-esophogeal

Reflux Disease (GERD).

Nausea/Vomiting.

Gastric Ulcers.

Potential

Complications:

Obstruction.

Ulcers.

GERD.

Slippage/migration.

Erosion.

L. Kathleen Mahan, S. E.-S. (2012). Krause's Food and the Nutrition Care Process (13 ed.). St. Louis, Missouri: Elsevier.

Weight Loss Surgery

Eligibility Criteria ◦ BMI of ≥ 40

◦ BMI ≥35 but <40 + weight related comorbidity T2DM

HTN

CVD

OSA

Metabolic Syndrome

Other

Murali MD, Sameer. “Bari-Babies: The New Frontier of Weight Loss Surgery, Pregnancy, and Lactation." California WIC Association Annual

Conference. The Fairmont Hotel, San Jose, CA. 23 April 2013.Workshop Session.

Weight Loss Surgery

Nutritional Implications

◦ Deficiencies

◦ Digestion

Supplements

◦ Life long

◦ Protein

◦ B12*

◦ Iron*

◦ Folate

◦ Calcium

Weight Loss Surgery

Physical Implications

◦ Overweight?

◦ Lose skin

◦ Softer pendulous breasts

Other Factors

2 ½ to 3 ½ times more likely to stop BF

Only 29% “believed” less successful

74% “agreed” that obese women are not more or less successful

42% “believed” it’s large breasts

“Majority” advised mothers no differently

Lack of guidance & advice

Other Factors

Labors

◦ More likely to have longer labors-stressors

◦ More likely to have labor complications

◦ Cesarean rates increase with BMI increase

◦ More likely to have PCOS

Breast size not to blame?

Other Factors

Pacifier Use

Less:

◦ Information provided

◦ Staff assistance

◦ Breastfeeding 1st hour

◦ Receiving resources

◦ Rooming in

◦ On demand

Stigma?

http://www.cdc.gov/prams/

http://scottq.blogspot.com/2012/04/is-discrimination-acceptable-fat-people.html

http://www.obesityaction.org/weight-bias-and-stigma

Group Activity

Get into groups

At least 3 ideas

◦ Biological, physiological, physical, behavioral, or

cultural, or environmental.

Share 1 or 2 ideas with the group

Support and Advice

Obesity

Duration Encouraging maximum stimulation Skin-to-skin

Baby wearing

Freq feedings

Pumping if needed

Position and latching ◦ Supporting large (pendulous) breasts

◦ Positioning

Support and Advice

Weight Loss Surgery

◦ Positioning & Latch

Excessive lose skin, skin rolls

Supporting large breasts

Duration

Encouraging maximum stimulation

Skin-to-skin

Baby wearing

Freq feedings

Pumping if needed

Support and Advice

Weight Loss Surgery

◦ Ensure they are taking their vitamins

Ca, B12, Fe, MVI

Blood work

◦ Infant weight & growth

◦ Check for infant lethargy

◦ Blood work

Support and Advice

Support and Advice

Resources

◦ LLL

◦ WIC

◦ Mom groups

◦ Websites

◦ Apps

◦ Counseling

◦ Nursing attire

Support and Advice

Resources

◦ http://www.cdph.ca.gov/programs/wicworks/Pages/WICBreastfeeding.aspx

◦ http://www.llli.org/llleaderweb/lv/lvmayjun89p35.html

◦ Text4baby

◦ BF Guide (Texas dept PH & WIC)

◦ LactMed

◦ LatchME

◦ Breastfeeding Solutions

Support and Advice

http://www.motherhood.com/maternity/plus-size-maternity-bras.asp

http://www.barenecessities.com/Nursing--Maternity-Bras-Plus-Size-Bras_catalog_nxs,47,style,12.htm?cmp=XMAS25

http://www.breakoutbras.com/category/plus-size-nursing-bras

http://www.nursingbraexpress.com/catalog/nursing-bras

http://ladygrace.com/nursning-maternity-bra/c/1115/

http://www.boobybooster.com.au/index.php

Thank You!

Bibliography Carmina, Enrico & Lobo, Rogerio A. Polycystic Ovary Syndrome (PCOS):

Arguably the Most Common Endocrinopathy is Associated with Significant

Morbidity in Women. Journal of Clinical Endocrinology & Metabolism. 1999

June;84 (6): 1897-9.

Cecilia Jevitt, C. P., Ivonne Hernandez, M. R., & Maureen Groer, R. P. (2007).

Lactation Complicated by Overweight and Obesity; Supporting the Mother

and Newborn. Midwifery & Women's Health , 52 (6), 606-613.

Celiker MY, C. A. (2009, September). Congenital B12 deficiency following

maternal gastric bypass. Perinatol , 640-642.

Flint, D.J., et.al (2005) Diet-induced obesity impairs mammary development

and lactogenesis in murine mammary gland. AJP-Endocrinol Metab, 288:

E1179-E1187

Grange DK, F. J. (1994). Nutritional vitamin B12 deficiency in breastfed

infant following maternal gastric bypass. Pediatr Hematol Oncol , 311-318.

Jan Riordan, K. W. (2010). Breastfeeding and Human Lactation (Fourth ed.).

Sudbury, Massachusetts: Jones and Bartlett.

Bibliography Laura Kair, Tarah Colaizy. Breastfeeding Medicine; vol 9, supplement

1, 2014. Abstracts. Pg. S-2. Obese Mothers Report Less Breastfeeding Support: Data from Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2008.

Kathleen M. Rasmussen, V. E. (2006). A Description of Lactation Counseling Practices That Are Used With Obese Mothers. Journal of Human Lactation , 22 (3), 322-327.

Kominiarek, M. A. (n.d.). Preparing for a pregnancy after bariatric surgery. Retrieved from http://www.glowm.com/pdf/section6_chapter29.pdf

L. Kathleen Mahan, S. E.-S. (2012). Krause's Food and the Nutrition Care Process (13 ed.). St. Louis, Missouri: Elsevier.

Danielle G. Lemay, Olivia A. Ballard, Maria A. Hughes, Ardythe L. Morrow, Nelson D. Horseman, Laurie A. Nommsen-Rivers. RNA Sequencing of the Human Milk Fat Layer Transcriptome Reveals Distinct Gene Expression Profiles at Three Stages of Lactation. PLoS ONE, 2013; 8 (7): e67531

Bibliography Manuel Ruz, F. C.-f. (2011). Zinc absorption and zinc status are reduced

after Roux-en-Y gastric. The American Journal of Clinical Nutrition , 1004-

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Marasco, L et.al. Polycystic Ovary Syndrome: A Connection to Insufficient

Milk Supply?. J Hum Lact. 2000 May; 16(2):143-8.

Mrion Lamb, R. M. (2011). Weight-Loss Surgery and Breastfeeding. Clinical

Lactation , 2-3, 17-21.

Murali MD, Sameer. “Bari-Babies: The New Frontier of Weight Loss Surgery,

Pregnancy, and Lactation." California WIC Association Annual Conference.

The Fairmont Hotel, San Jose, CA. 23 April 2013.Workshop Session.

Phyllis Kombol, R. M. (2008). Breastfeeding After Weight Loss Surgery. ILCA's

Inside Track.

Preidt, R. (2013, August 5th). Whites are Heavier Users of Weight-Loss

Surgery, Study Finds. HealthDay , p. 1.

Bibliography Ruth A. Lawrence, R. M. (2011). Breastfeeding A Guide for the Medical

Profession (Seventh ed.). Maryland Heights, Missouri: Elsevier.

Terrance D. Wardinsky, M., Vicki Snnhuber, P., Dennis Bartholomew, M.,

Ramon G. Montes, M., Richard L. Friedrich, M., & Robert B. Broadhurst, M.

(1995, November). Vitamin B12 Deficinecy Associated with Low Breastmilk

Vitamin B12 Concentration in an INfant Following Maternal Gastrci Bypass

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Vanky, E. et.al. Breastfeeding in Polycystic ovary syntrome. Acta Obstet

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Bibliography Centers for Disease Control and Prevention Healthy Weight Assessment

http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html

National Institute of Health Definition of Obesity http://www.nlm.nih.gov/medlineplus/obesity.html

Science Daily. Why Some Women Don't Have Enough Breastmilk for Baby: Important Role of Insulin in Making Breast Milk Identified July 5, 2013 http://www.sciencedaily.com/releases/2013/07/130705212228.htm

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