Monday, December 15, 2008

Pregnancy After Weight Loss Surgery

I had already planned an entry on pregnancy after Weight Loss Surgery (WLS) to address the recent study purporting to show that WLS made pregnancy in fat women safer.

However, Sandy from Junkfood Science beat me to it. And really, there's no need to re-invent the wheel when someone else has already done it far more completely than I'd ever have time for. So if you want to read about the weaknesses of this study and how there really are still significant concerns about pregnancy after WLS, be sure and go read Sandy's entry.

But while Sandy has done the heavy lifting on this one, let me just add some comments.


First of all, let's not vilify people who have had this surgery. I am strongly against WLS but I also understand what drives many people to do it. Several friends of mine have done it, despite my strongly expressed concerns over the potential consequences. I empathize with their reasons, even while I disagree with how they are going about addressing their concerns.....but ultimately it is their body and they have the final say about what they do with it. I just pray now that the nutritional repercussions are not too severe because I truly love my friends and I want the best for them.

To be fair, let's also point out that many women have had seemingly successful pregnancies after WLS. Their babies seem to have been born healthy and fine, with no major obvious issues. For their sake, I am glad their babies seem to be fine, and I genuinely rejoice with them for their new little ones.

I have to be honest, though, and say that I fear what impact this might have on the baby long-term that we are not able to see now. Just because a baby is born with no obvious problems does not mean that it was not affected. The doctors seem far too content to say, 'Look, no obvious birth defects or problems at birth; see, pregnancy after WLS is perfectly safe!!' Actually, we know no such thing.

In fact, one of the important points this review missed was that there is an increased rate of small-for-gestational-age (SGA) and/or IUGR (intra-uterine growth retardation) babies in some of the research. I've seen studies where the abstract proudly announces that outcomes were more "normalized" among the women with WLS, that no bad outcomes resulted from the pregnancies after WLS in the study.

Yet, when you look closer, hidden in the full text is the finding, carefully shrugged off, that there was a higher rate of SGA and/or IUGR babies in the women who'd had WLS before pregnancy. And we know that these babies have higher rates of all kinds of health problems. Yet this issue gets hardly any press.

Another problem is whether or not the outcomes of pregnancies after WLS are being selectively reported. I have heard anecdotal reports of poor outcomes from women who are on WLS support boards, as well as from doulas and midwives who have worked with pregnancies after WLS. While many women have seemingly done well, there are also quite a few miscarriages happening, as well as some babies with birth defects.....yet few if any of these stories are being documented in the research that I've read.

That certainly suggests the possibility that poor outcomes of pregnancies after WLS are being under-reported. What kind of accountability is there for making sure that all outcomes of pregnancy after WLS are being recorded and reported? Is it simply a matter of poor tracking after WLS? Or is that women who have poor outcomes are not reporting them to their WLS surgeons? Or could it be that some WLS surgeons are selectively reporting to feature only the best outcomes?

One of my biggest concerns about this whole issue is that the people who are responsible for doing the research and reporting about it are the ones with the biggest economic interest in it. It's like asking the tobacco industry to be the sole group investigating and reporting on the effects of cigarettes. Or asking the pharmaceutical industry to sponser all the research about a certain drug and report these findings without any oversight or independent investigation to confirm or repudiate their findings.

Research on WLS is mostly done by WLS doctors. On the surface, this is logical, as they are the ones in the trenches every day, seeing patients, and the ones with the data in their files to pull from. But WLS is a profoundly profitable industry these days; greed (and prejudice about "saving" fat people from themselves) makes it easy for data to get distorted or selectively reported.

Frankly, in WLS research, far too much data conveniently gets "lost" to follow-up, and there is little or no accountability from outside, independent agencies. There needs to be far more independent oversight and investigation from people outside both the weight loss and the weight loss surgery industries.

Another thing that really bothers me about WLS (especially Gastric Bypass) is the aggressive marketing of it to childbearing-aged women, as if no fat woman on earth could possibly have a healthy pregnancy or baby without losing weight first. While it's true that there are risks associated with 'obesity' and pregnancy, it's also true that the MAJORITY of fat women have healthy babies just fine, and that prevention of complications in this group does not have to involve weight loss or dietary restriction.

It's not an either/or proposition....but you'd never know that from the marketing on some WLS websites. A lot of fat women are having WLS because they have been convinced that WLS may be their only way to have a pregnancy or a healthy baby, and that's simply not true.

Furthermore, aggressively marketing WLS to childbearing-aged women as the "best" way to ensure a healthy pregnancy and baby while we still know so little about the long-term effects of malabsorptive procedures on the baby seems horribly unethical to me. The long-term nutritional effects of WLS can be so devastating for the mother; how do we really KNOW it's going to affect a baby, both short-term and long-term?

Malabsorptive procedures bypass parts of the digestive system that absorb certain nutrients. At first, the woman's own body reserves are enough to sustain her, and the massive amounts of supplements taken after WLS help make up the difference. For some, that's enough.....but for many it is not. Most women of childbearing age face significant nutrient deficits after several years, once their own reserves are used up and they stop absorbing the supplements as well.

If a woman is not able to absorb enough iron, B12, calcium, vitamin D, folic acid, etc. after WLS to keep up her own levels long-term, how in the world is she going to be able to lay down sufficient quantities of this for a growing, developing baby? What are the possible long-term effects this could have on babies?

I realize that most women who have babies after WLS get pregnant within 1-3 years or so, while they still have some nutritional reserves. And this is probably what has saved the babies of these pregnancies so far....they are able to draw on the mother's nutritional reserves to absorb sufficient stores for their own development....but are they really receiving optimal amounts of these nutrients?

For example, after WLS, many women have so much trouble absorbing enough calcium and vitamin D that osteoporosis and/or rickets is a real risk later on. It takes years for most people to get to this kind of deficit, but it's a process of malabsorption that takes place gradually over time. So even if pregnancy takes place within a couple of years after WLS, are babies in these pregnancies truly absorbing enough during a pregnancy for their bones to be fully mineralized properly? Will they pay a price later on in life? Frankly, I have yet to see anyone properly examine that question in research but it certainly is one of my concerns.

Yes, vitamin supplements help compensate for the gut's decreased ability to absorb these nutrients, but many women become nutritionally compromised, even while taking supplements. If they can't support their own bodies' needs over time, even while on supplements, are they really able to fully support a baby's needs? What kind of long-term effects will there be from compromised access to B12, iron, vitamin D, calcium, vitamin A, etc.? I just don't think we know this yet.....and no one seems to be asking the question at all.

I wonder if what we've got here is akin to babies born during times of famine. Yes, even on a famine diet of significantly reduced calories and nutrients, many babies are born "okay" and seem like they are fine. It's a tribute to the remarkable adaptability of the fetus in utero that babies survive even under the least desirable of conditions, like famine. And yet, research clearly shows that babies born during times of famine are affected by that lack of nutrients; more develop diabetes, hypertension, obesity, and a host of other issues.

Of course, pregnancy after WLS is not exactly the same as pregnancy during a true famine. Women after WLS get more calories and probably more variety of foods than women during a famine. On the other hand, women in famine still have their full digestive and absorption capabilities, so they can at least make better use of the calories and nutrients they are getting. So, obviously, pregnancy during famine and pregnancy after WLS are not exactly the same thing, and it's difficult to draw too many broad conclusions.

Yet it's also clear that pregnancy during famine is not entirely a benign thing, and animal models clearly show that deprivation during pregnancy can have long-term consequences for offspring. Doesn't pregnancy after WLS have the potential for similar consequences? Seems like a logical concern, yet the WLS industry is completely shrugging these potential concerns off.

As far as I know, there are NO long-term studies of the offspring of WLS pregnancies. They can hardly manage to document decent percentages of WLS pregnancies for study as it is now (see Sandy's piece); there doesn't seem to be anything in place for long-term foll0w-up of the children of these WLS pregnancies years later.

So the question remains.....are we creating more long-term problems than we are solving? Will we face an epidemic of other health problems in these children 30, 40, or 50 years down the road? Is ANYONE even trying to investigate this? And who is overseeing the surgeons with their hands in the monetary goody jars?

I have great empathy for people considering WLS. Although I sincerely believe they are making a choice that often worsens health over the long run, I understand some of the reasons why many of them consider it. Although it's a choice I'd never make, it's their body, their choice.

However, I do not believe that a "safer pregnancy" or a "healthier baby" should be one of those reasons. The research on this topic is far too spotty in quality, too subject to selective reporting, too lacking in long-term follow-up, and too prone to bias because it's done by those with a vested economic interest in promoting it.

5 comments:

spacedcowgirl said...

I have--and have always had, based simply on the fact that WLS rearranges your whole digestive system and means of absorbing nutrients--the same serious concerns about long-term consequences of WLS, the assumption that if it results in weight loss that automatically means you are healthier, and the question of whether anyone is looking into this and whether we will have answers before it is too late for all the people who are flocking to get WLS these days. I never thought about it in connection to pregnancy, though. Thank you for all that additional information. I don't think I'd ever get WLS anyway (unless something I can't foresee drastically changed with my health and somehow caused it to seem like the right choice... I don't see that happening, though), but these concerns give me another reason to rule it out. WLS aside, I think it is insane how much pressure to lose weight (even during the pregnancy itself) fat TTC/expectant mothers face these days. I can't help but think the "solution" (dieting/attempted weight loss) is more damaging than the "problem" (being fat) in most cases.

MJK said...

I would like to see a long term study done of these mothers down the road. I am currently pregnant and one of the things I have been told over and over is, "If you do not get the calcium the baby needs, it will take it from your bones."
I would not be surprised to see the osteoporosis rates skyrocket for these poor women.

Well-Rounded Mama said...

Ashley, I approved your comment but it seems to have gotten lost in the ether. I'm sorry. It's not appearing here, at least not yet. However, I understand your concerns and wanted to address them.

A wt loss in the first few months of pregnancy is really not unusual at all for women of size. Less common in an "in-betweenie" but still not unheard of. Although I am staunchly against doctors trying to encourage such a thing in women of size, if you are eating normally and healthfully and still experience a loss at first, it's really a very common pattern. At some point you will start regaining the weight, usually around the middle to end of the 2nd trimester, and will end with a small net gain.

However, you mentioned HG, by which I assume you mean Hyperemesis Gravidum, which is a stronger concern. I hope you will get hooked up with some of the online support for women with HG because it's no fun and definitely needs to be watched carefully.

You may also want to read up on my website (www.plus-size-pregnancy.org) on dealing with pregnancy nausea...the section needs updating but it's got some ideas that have helped some folks. If you are borderline HG, perhaps some of these might help you. For me, the very strong nausea I had in preg #1 was helped by eating small amounts of protein and carbs very very frequently, every 2 hours at least. Even if I threw it up, I went back and ate a little afterwards (after a bit of time). Frequent protein was the key for me, along with respecting my cravings and aversions. More recently, I've learned that acupuncture can be amazing for some people with strong nausea; it's not a cure for all HG, mind, but it does help a significant percentage, and it's unlikely to be harmful. Check it out. If none of this helps the HG, there are drugs that can be used, but research them carefully and consider the pros and cons first.

As for more info about pregnancy and weight gain in women of size, check out the categories on the side of this blog. I have a whole series of posts about the topic.

Best wishes, and hope you start feeling better soon.

Hiyaaah! said...

(Hi; I'm here from Shapely Prose.)

So "research clearly shows that babies born during times of famine are affected by that lack of nutrients; more develop diabetes, hypertension, obesity, and a host of other issues"? You mean, the kind of issues we've seen becoming more and more common, in a society where a lot of women diet chronically and worry about gaining 'too much' weight even during pregnancy? Fancy that.

I wonder if anyone is studying possible correlations, because that could explain a lot. Suppose women diet for 12-18 months before the wedding, then get pregnant right afterward when their reserves are still low. Would that have an effect?

Anonymous said...

What is amazing that in 2014 the same suspect rubbish of bariatric surgery being so good for weight loss and hence pregnancy is still promoted strongly. The slight acknowledgement was fleetingly rementioned that some such former patients had a few IUGR, small for dates babies. The only additional point was that the obstetricians of these women were recommended to consider this option while monotoring them.
There is no doubt that this surgery compromises fully effective nutritional absorbtion or how sensitive the fetus is in the nutrient availability and types to being compromised.It's the height of irresponsability to recommend women to have this surgery before completing childbearing and stupidity to accept it.