obesity, gastric bypass, &...
TRANSCRIPT
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
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
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%
Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2012
*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.
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
http://www.cdc.gov/obesity/data/prevalence-maps.html
15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%
Prevalence* of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013
*Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.
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
http://www.cdc.gov/obesity/data/prevalence-maps.html
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
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
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
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
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
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
Bibliography Carmina, Enrico & Lobo, Rogerio A. Polycystic Ovary Syndrome (PCOS):
Arguably the Most Common Endocrinopathy is Associated with Significant
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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.
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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
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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.,
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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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