Childhood Obesity and Coronary Artery Disease
A study appearing the the December 6, 2007 issue of the New England Journal of Medicine significantly connects childhood weight to adult risk of coronary artery disease. Danish researchers looked at 277,000 children born from 1930 to 1976 and found that those with higher BMIs were significantly more likely to have heart disease as adults. Researchers further predicted that with the global rates of childhood obesity rising, that this will lead to a potentially epidemic rise in adult coronary disease in the next 3 decades.

Baker JL, Olsen LW, Sørensen TI. Childhood body-mass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007 Dec 6;357(23):2329-37.

Sleeve Gastrectomy Gaining Acceptance
A study headed by Peter F Lalor, MD from Northeast Surgery in Bangor, Maine, and presented at the 2007 meeting of the American Society for Metabolic and Bariatric Surgery, has demonstrated that the laparoscopic sleeve gastrectomy has similar complication rates as other bariatric surgical procedures. The study examined results for 149 patients over three years. Why surgeons caution that more data, especially long-term data, is needed, these results are considered to be encouraging by those performing the procedure.

A controlled study of peripheral neuropathy
A controlled study of peripheral neuropathy after bariatric surgery.

U.S. National Library of Medicine Neurology. 2004 Oct 26;63(8):1462-70. Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, Norell JE, Dyck PJ.

BACKGROUND: Although peripheral neuropathy (PN) occurs after bariatric surgery (BS), a causal association has not been established.

OBJECTIVES: To ascertain whether PN occurs more frequently following BS vs another abdominal surgery, to characterize the clinical patterns of PN, to identify risk factors for PN, and to assess if nerve biopsy provides pathophysiologic insight.

METHODS: Retrospective review identified patients with PN after BS. The frequency of PN was compared with that of an age- and gender-matched, retrospectively evaluated cohort of obese patients undergoing cholecystectomy.

RESULTS: Of 435 patients who had BS, 71 (16%) developed PN. Patients developed PN more often after BS than after cholecystectomy (4/126; 3%) (p < 0.001). The clinical patterns of PN were polyneuropathy (n = 27), mononeuropathy (n = 39), and radiculoplexus neuropathy (n = 5). Risk factors included rate and absolute amount of weight loss, prolonged gastrointestinal symptoms, not attending a nutritional clinic after BS, reduced serum albumin and transferrin after BS, postoperative surgical complications requiring hospitalization, and having jejunoileal bypass. Most risk factors were associated with the polyneuropathy group. Sural nerve biopsies showed prominent axonal degeneration and perivascular inflammation.

CONCLUSIONS: Peripheral neuropathy (PN) occurs more frequently after bariatric surgery (BS) than after another abdominal surgery. The three clinical patterns of PN after BS are sensory-predominant polyneuropathy, mononeuropathy, and radiculoplexus neuropathy. Malnutrition may be the most important risk factor, and patients should attend nutritional clinics. Inflammation and altered immunity may play a role in the pathogenesis, but further study is needed.

Effectiveness of selenium supplements
Yiming Xia, Kristina E Hill, Daniel W Byrne, Jiayuan Xu and Raymond F Burk

Background: Selenium is an essential micronutrient with a recommended dietary allowance for adults of 55 µg/d. It functions as an essential constituent of selenoproteins. Although there is no evidence of selenium deficiency in the United States, people in many other areas of the world are selenium deficient, with the consequence that they are unable to express their selenoproteins fully.

Objective: We carried out a supplementation trial in a selenium-deficient population in China to assess the requirement for selenium as selenite and as selenomethionine.

Design: One hundred twenty subjects with an average selenium intake of 10 µg/d were randomly assigned and administered tablets containing no selenium or amounts as high as 66 µg Se/d for 20 wk. Plasma was sampled before supplementation and at 4-wk intervals during supplementation and was assayed for the 2 plasma selenoproteins, glutathione peroxidase and selenoprotein P.

Results: Full expression of glutathione peroxidase was achieved with 37 µg Se/d as selenomethionine and with 66 µg/d as selenite. Full expression of selenoprotein P was not achieved at the highest doses of either form.

Conclusions: Full expression of selenoprotein P requires a greater selenium intake than does full expression of plasma glutathione peroxidase. This suggests that selenoprotein P is a better indicator of selenium nutritional status than is glutathione peroxidase and that the recommended dietary allowance of selenium, which was set with the use of glutathione peroxidase as the index of selenium status, should be revised. Selenium as selenomethionine had nearly twice the bioavailability of selenium as selenite.

Multivitamins may support healthy weight loss

November 2007 - Two studies published in late November the British Journal of Nutrition indicate that taking a multivitamin and mineral supplement may assist in weight management. The first study reported on a survey of survey of 267 men and 320 women aged 20 to 65. The survey found that in men regularly taking a dietary supplement weighed less, had less body fat, and lower BMI than those who did not. Women reported similar results, as well as generally reduced appetite.

In the second study, obese patients were placed on a low calorie diet and either given a multivitamin or placebo. While both group lost weight equally, those taking the multivitamin reported significantly reduced hunger both between and after meals.

G.C. Major, E. Doucet, M. Jacqmain, M. St-Onge, C. Bouchard, and A. Tremblay. Multivitamin and dietary supplements, body weight and appetite: results from a cross-sectional and a randomised double-blind placebo-controlled study. Br J Nutr. 2007 Nov 1;:1-11

Follow Up is Important to Success

Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass

December 2007 - A new study confirms what many people have long felt to be true: that patients who take their follow-up care the most seriously have the best results after gastric bypass surgery. The study compared patients who came to all follow-up visits for three years, to those who stopped after one year, to those who stopped before one year. Those who came to all scheduled appointments had the greatest weight loss at three years.

Dietary Fish Oil and Weight Gain
A study published in December 2007 in the Journal of Nutrition compared two groups of mice on high fat diets. In one group, 8% of the fat calories came form fish oils high in Omega-3 fatty acids, in the other it did not. The high fish oil group gained less weight and metabolised more fat than the control. The high fish oil diet was further found to improve fat metabolism-related enzyme activity, including fatty acid beta-oxidation, omega-oxidation, and malic enzyme activities in the small intestine.

Mori T, Kondo H, Hase T, Tokimitsu I, Murase T. Dietary fish oil upregulates intestinal lipid metabolism and reduces body weight gain in C57BL/6J mice. J Nutr. 2007 Dec;137(12):2629-34.

ASMBS Position on Sleeve Gastrectomy
December 2007 - Following a review of 15 published peer-reviewed studies on the short-term outcomes of the sleeve gastrectomy procedure, the American Society of Metabolic and Bariatric Surgery has adopted an initial position statement. Based on the current body of evidence, the ASMBS has stated that this procedure "may be an option for carefully selected patients, particularly those who are high risk or super-super-obese." They further recommend that doctors collect and report data on these cases, and encourage surgeons to inform patients of the limited data on this procedure while assuring they understand the better-studied surgical options.

Sleeve gastrectomy as a bariatric procedure. Surg Obes Relat Dis. 2007 Nov-Dec;3(6):573-6.

Sclerotherapy as possible treatment for dilation
One possible cause of weight gain in post-operative gastric bypass patients is the dilation of the gastojejunostomy. 32 cases of patients who underwent sclerotherapy (an injection of sodium morrhuate to sclerose or scar local tissue) between 1999 and 2006 were reviewed. 75 percent of the treated patients lost weight while the remaining 25 percent had weight stabilization after this procedure.

Long-term Results of Sclerotherapy for Dilated Gastrojejunostomy After Gastric Baypss

Calcium Citrate May Not Cause Kidney Stones
DALLAS—Calcium citrate supplementation alone or in combination with potassium citrate does not increase the risk of kidney stones in healthy postmenopausal women, according to a study published in the September issue of The Journal of Urology (172, 3:958-61, 2004).

In the randomized clinical trial of four two-week phases, 18 postmenopausal women without stones received twice-daily supplementation with 400 mg calcium citrate, 20 mEq potassium citrate, calcium citrate and potassium citrate (at same doses) or placebo. During the last two days of each phase, urine samples were obtained in 24-hour pools and analyzed for stone risk. Compared to placebo, calcium citrate increased urinary calcium and citrate, decreased urinary oxalate and phosphate and did not affect urinary saturation of calcium oxalate, brushite and undissociated uric acid.

Potassium citrate decreased urinary calcium, increased urinary citrate and pH, decreased urinary saturation of calcium oxalate and undissociated uric acid, and did not change the saturation of brushite. When calcium citrate was combined with potassium citrate, urinary pH increased, saturation of brushite increased, levels of urinary undissociated uric acid decreased, levels of urinary calcium remained elevated, urinary citrate levels increased, and urinary oxalate levels decreased, thereby slightly decreasing the urinary saturation of calcium oxalate.

The researchers concluded calcium citrate supplementation does not increase the risk of stone formation in healthy postmenopausal women, and the co-administered potassium citrate may provide additional protection against formation of uric acid and calcium oxalate stones.

Dairy Calcium May Help Slim Adolescent Girls
MANOA, Hawaii — Scientists at the University of Hawaii have linked dairy calcium intake with lower iliac skinfold thickness (a measure of body fat) and body weight, according to a study published in the August 2004 issue of the Journal of Nutrition (134, 8:1905-09, 2004).

The study examined the body fat and weight of 323 Pacific Islander and Asian girls, aged 9 to 14 years, in relation to age, ethnicity and physical activity. Subjects were surveyed for mean age, calcium intake, weight and iliac skinfold thickness.

Calcium intake, age and physical activity were found to have significantly negative associations with iliac skinfold thickness, whereas height, Tanner breast stage and Pacific Islander ethnicity were found to have significantly positive associations. One mg of total and dairy calcium was significantly associated with lower iliac skinfold thickness and one milk serving was associated with 0.78 mm iliac skinfold thickness. Nondairy calcium was not associated with weight or iliac skinfold thickness. In addition, soda intake was significantly positively associated with weight in both models.

The researchers concluded decreasing soda intake and increasing dairy consumption among Asians may help maintain body fat and weight during adolescence.

Low Vitamin A Paves Road to Iron Deficiency
DAVIS, Calif.--According to a study published in the January issue of The Journal of Nutrition (135:27-32, 2005) low maternal levels of vitamin A may leave breastfed offspring at risk for iron deficiency. University of California researchers hypothesized low vitamin A intake during lactation elicits differential effects on mammary gland and liver iron transport and storage proteins, thus affecting the iron concentration in milk, but not maternal iron status.

A positive correlation between maternal iron status and iron levels in milk were observed in lactating women supplemented with both vitamin A and iron, but not with iron alone. The scientists fed rats either a control diet or a marginal vitamin A diet--containing one-tenth of the vitamin A given in the control diet--through mid-lactation. Effects on plasma, milk, liver and mammary gland iron and vitamin A concentrations, and divalent metal transporter-1 (DMT1), ferroportin (FPN), ferritin, and transferrin receptor (TfR) expression were determined. The rats fed the vitamin A diet were not vitamin A or iron deficient at the onset of the study.

Milk and liver vitamin A and iron levels, as well as mammary gland iron concentrations were lower, liver TfR expression was higher, and mammary gland TfR expression was lower in rats fed the vitamin A diet compared with rats fed the control diet. Liver Ft was unaffected, yet mammary gland ferritin was lower in the vitamin A fed rats compared with those on the control diet. Liver and mammary gland DMT1 and FPN protein levels were lower in the vitamin A rats compared with the control.

The researchers concluded the mammary gland and the liver respond differently to marginal vitamin A intake during lactation, causing iron levels in milk to become significantly decreased due to effects on mammary gland iron transporters, thereby putting the nursing offspring at risk for iron deficiency.

Iron, B12 and Folate after Sleeve Gastrectomy
A new study has shown that there is a risk of B12 and folate deficiency, and a lesser risk of iron deficiency one year after vertical sleeve gastrectomy. 151 patients who underwent the vertical sleeve gastrectomy procedure in Saudia Arabia, had their labs followed for one year. The incidence of B12 deficiency increased from 8.1% pre-operatively to 26.2% post-operatively. Folate deficiency developed in 9.8% of patients and iron deficiency developed in 4.9% of patients. These findings suggest that vertical sleeve gastrectomy patients are at nutritional risk based on their procedure and should be monitored for deficiency after surgery.

Hakaem HA, O’Regan PJ, Salem AM, Bamehriz FY, Eldali AM. Impact of Laparoscopic Sleeve Gastrectomy on Iron Indices: 1 Year Follow-Up. Obes Surg. 2009 Jul 15.

Omega-3 Fatty Acids and Obesity
New research published in the British Journal of Nutrition has shown that people with lower body mass indexes (BMI) have higher blood levels of essential fatty acids such as EPA and DHA.  The researchers looked at 124 subjects and classified them by BMI as normal weight, overweight, or obese. Obese people had omega-3 levels of 4.53 per cent, compared to 5.25 per cent in their healthy-weight peers.  Researchers do not yet know whether essential fatty acids play any role in helping people to lose weight or to maintain weight loss. It is not clear from the results of this study if the link is causal or a simple correlation, however researchers are hopeful that future studies will help to answer these questions.  Essential fatty acids are known to support other areas of health such as brain, eye and cardiovascular health.

Source: British Journal of Nutrition
 Published online ahead of print, doi: 10.1017/S0007114509382173
 â€œPlasma n-3 polyunsaturated fatty acids are negatively associated with obesityâ€�
 Authors: M. Micallef, I. Munro, M. Phang, M. Garg

Chromium Picolinate and Memory

March 2008. A new study shows that chromium picolinate my improve brain activity and cognitive function in the elderly.

Researchers at the University of Cincinnati have shown using fMRI that daily supplements of chromium picolinate at 1000 mcg/day improved the brain activity of elderly individuals after a 12 week trial. The most significant results were seen in those showing early signs of memory decline. These results are part of an on-going trial and are yet unpublished.

Bariatric Surgery Helps Back Pain

19 April, 2008 - A study conducted at the University of Southern California has shown that gastric bypass surgery greatly improves low back pain. 38 consecutive patients with low back pain underwent gastric bypass surgery for obesity. At six months post-operative, there was a 44 percent decline in thier average pain scores.

This study is due to be presented on April 29 during the annual meeting of the American Association of Neurological Surgeons in Chicago.

Probiotics and Gastric Bypass
John Morton, MD at Stanford University has been conducting ongoing research into the use of probiotics in post-operative gastric bypass patients.  The study, stared in 2006, has followed 44 patients.  Half the patients were instructed to take a daily probiotic, the other half took nothing.  The initial outcome that Morton and his team were looking for was improved Quality of Life (QoL) markers, especially fewer digestive complaints.  While they did find benefits for general GI complaints, the surprising results were improved weight loss and higher B12 levels.  At six months, had a 7% greater excess weight loss compared to the control and higher B12 levels.  While the weight loss was considered “not-significantâ€� by statistical measures, it is certainly interesting enough to beg more research into the influence of probiotics on weight.

Woodard GA, Encarnacion B, Downey JR, et al. Probiotics improve outcomes after Roux-en-Y gastric bypass surgery: a prospective randomized trial. J Gastrointest Surg 2009 Jul;13(7):1198-1204.
study: doi 10.1007/s11605-009-0891-x

A Case of B1 Deficiency in a RNY Patient After Plastic Surgery

The January 2010 issue of Surgery for Obesity and Related Diseases (SOARD) reports on a case of acute thiamine (B1) deficiency after plastic surgery in a patient with a history of gastric bypass. The patient underwent multiple, successful procedures including panniculectomy, face lift and brachioplasty (arm lift), however she developed symptoms of neurological deficit during recovery. For several days her medical team pursued a cause for the symptoms without success. On day 3, empiric therapy with intravenous thiamine was tried, providing for significant symptomatic improvement within hours. Over the next 48 hours, with continued “aggressive thiamine therapy� the patient made a full recovery. Cosmetic surgery, which often involves large incisions, can be taxing on the nutritional stores of the body. Many nutrients are required for wound healing – such as protein, zinc and vitamin C – however many more are conditionally essential meaning that a patient might have normal/borderline levels that are simply inadequate to meet the demands of surgery. While thiamine is not often thought of as a wound healing nutrient, the body stores very little and deficiency can be induced by administration of glucose. Doctors in this case suspect that deficiency may have been brought about by a combination of marginal levels in the patient coupled with the administration of a glucose-containing IV over the many hours of a lengthy set of procedures. Reference: Sebastian JL, Michaels JM, Tang LW, Rubin JP. Thiamine deficiency in a gastric bypass patient leading to acute neurologic compromise after plastic surgery. Surg Obes Relat Dis. 2010 Jan-Feb;6(1):105-6. Epub 2009 May 18. Abstract: Click Here

Adjustable gastric banding better than diet for obese teens.

An Australian study published in JAMA on February 9, 2010 looked at the outcomes of gastric banding versus diet therapy in obese teens (ages 14-18). In the study 25 teens were given a gastric band and the other 25 were placed in a lifestyle intervention group. 84% in the gastric banding group lost more than 50% of excess weight compared to 12% in the lifestyle group. The gastric banding group also showed significant improvements in obesity-related health conditions such as hypertension and metabolic syndrome. Reference: O'Brien P, et al "Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial" JAMA 2010; 303: 519-26. The full text of this study is available here: http://jama.ama-assn.org/cgi/content/full/303/6/519

New research Supports Calcium Citrate Over Carbonate After RNY Gastric Bypass.
New research conducted at the University of Texas Southwestern Medical Center supports the use of calcium citrate over calcium carbonate after gastric bypass surgery. Calcium absorption is impaired after gastric bypass surgery as there is significantly less stomach acid as well as malabsorption from bypassing the duodenum. This study was a double-blind crossover study to compare the absorption of calcium citrate to calcium carbonate after gastric bypass. This is important as bone loss is a serious risk after surgery. Patients are asked to take large amounts of supplemental calcium after surgery, and these are the commonly supplemented forms. This study showed not only better absorption of calcium as calcium citrate, but also a greater decline in serum PTH levels in response to calcium citrate.

Source: Tondapu P, Provost D, Adams-Huet B, Sims T, Chang C, Sakhaee K. Comparison of the Absorption of Calcium Carbonate and Calcium Citrate after Roux-en-Y Gastric Bypass. Obes Surg. 2009 Sep;19(9):1256-61. Epub 2009 May 13. Click Here to view the source article.

Study Shows More Benefits of Preoperative Weight Loss
Study Shows More Benefits of Preoperative Weight Loss
A study published in the December 2009 in the Archives of Surgery shows that weight loss prior to gastric bypass surgery is significantly associated with a reduction in post-operative complications. 

The study, conducted at the Geisinger Medical Center in Danville, Pennsylvania, examined the detailed records from 881 patients who had bariatric surgery at the facility between 2002 and 2006.  All patients in the study had either open or laparoscopic gastric bypass surgery and all participated in a 6-month standardized pre-operative program.  As part of this program, patients are advised (but not required) to lose 10% of their excess body weight (EBW).  Of the 881 patients included in the study, some gained weight and some lost weight.  The authors of the study categorized patients by the amount of weight gained or lost in the preoperative period and compared this to postoperative complications in the same groups. 

A loss of 6-10% EBW was associated with the lowest incidence of 30-day postoperative complications for both open and laparoscopic procedures.  Those losing greater than 10% EBW also had significantly lower complication rates as compared to those who gained weight or only lost 0-5% excess weight. 

This data supports prior data from the Geisinger Center which showed that patients with 10% (or higher) preoperative EWL had shorter postoperative hospital stays, indicating that the likely reason is the reduced rate of complications found in the current analysis.

While the authors stop short of suggesting that all patients undergoing bariatric surgery should be required to undergo preoperative weight loss, the do call for prospective, controlled trials to support their findings.

Reference: Arch Surg. 2009;144:1150-1155, 1155-1156.

Pregnancy outcomes after gastric bypass.

There a continued questions about the safety of pregnancy following bariatric surgery. Researchers at Allegheny General Hospital in Pittsburgh, Pennsylvania compared the perinatal outcomes of 26 bariatric surgery patients to both obese and non-obese controls. They found that postoperative patients had a rate of pregnancy complications similar to non-obese controls and statistically less than morbidly obese controls.

Patel JA, Patel NA, Thomas RL, Nelms JK, Colella JJ. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008 Jan-Feb;4(1):39-45.

Is folate deficiency a risk after WLS?

Folate Intake Still Inconsistent Among Women (From Natural Products Marketplace 7/3/07)

AUSTIN, Texas-A majority of women are still not supplementing with folic acid, despite encouragement from federal agencies to do so, with greater numbers of obese and non-white women failing to fight neural tube defects with the B vitamin. Up to 70 percent of neural tube defects of the brain and spinal cord can be prevented by consumption of folic acid by women before and early during pregnancy.

A new study from the Texas Department of State Health Services compared folic acid supplementation rates among obese, overweight and normal-weight women (J Obstet Gynecol Neonatal Nurs. 2007 Jul-Aug; 36(4)335-41). Among 6,835 study participants, 35 percent reported daily folic acid supplementation. Obese women were less likely to supplement, even after adjustment for other factors.

Similar findings were recently reported by the Centers for Disease Control and Prevention (CDC), which analyzed nutrient intake data reported by 1,685 nonpregnant women aged 15 to 49 years who participated in the 2001-2002 National Health and Nutritional Examination Survey (Am J Clin Nutr. 2007 May; 85(5):1409-16). Only 8 percent of nonpregnant women reported consuming at least 400 mcg/d of folic acid from fortified foods; among non-Hispanic black women, the percentage fell to 5 percent, compared to 6.8 percent of Hispanic women and 8.9 percent of non-Hispanic white women. A smaller percentage of non-Hispanic black (19.1 percent) and Hispanic (21 percent) women than non-Hispanic white women (40.5 percent) consumed at least 400 mcg/d folic acid from fortified foods, supplements or both, in addition to food folate.

Commentary

This recent data suggests that in the general population we still aren't doing enough to make sure that women of childbearing years get the nutrition they need to have a healthy pregnancy and healthy babies. This may be a particular concern with weight loss surgery. Why? Several reasons.

The majority of folate in the diet comes from folate-fortified foods such as bread and pasta. Most post-surgery diets eliminate or restrict these foods. Most patients still don't comply with a multivitamin long-term. In the absence of supplementation, bariatric surgery patients have been shown to have low folate and high homocysteine. For example:

Gasteyger et al recently reported a 41% decline in folate levels in Lap-Band patients 24 months post-op. (Obesity Surgery, 16, 243-250) This is often the time at which surgeons are giving patients the green light to get pregnant.

Madan et al found frank folate deficiency in 11% of RNYGB patients one year post-op. (Obesity Surgery, 16, 603-6)

Fertility can return rapidly in women who have been infertile due to obesity and/or insulin resistance. Despite being counseled to avoid pregnancy for 18 to 24 months, and to undergo nutritional counseling prior to pregnancy, women still become pregnant. Many bariatric surgery programs do not check folate status or homocysteine status.

We know that one great benefit of weight loss surgery is increased fertility. It is very important that women be advised of the potential consequences of becoming pregnant with inadequate nutritional status. Additionally, bariatric surgery programs should consider testing for folate status, at least in women who plan to become pregnant.

Probiotics Helpful After Gastric Bypass.
07/15/2009
STANFORD, Calif.—Taking probiotics after gastric-bypass surgery improves weight loss, vitamin B12 availability and bacterial growth, according to a new study from Stanford University.

The study (J Gastrointest Surg. 2009 Jul;13(7):1198-204) examined 44 patients who received either a daily supplement of 2.4 billion colonies of Lactobacillus or a placebo after Roux-en-Y gastric-bypass surgery. Both groups were allowed to eat yogurt, a natural form of probiotics.

After six weeks, the probiotic group attained significantly greater percent weight loss than that of control group. The weight loss trend continued at three months with the probiotics group losing 47.6 percent of their weight, compared with a 38.5 percent reduction for the control group, but was not significant six months after the surgery. At three months, significantly higher vitamin B12 levels were achieved in the probiotic group (1,214 picograms per milliliter in the probiotic group vs. 811 pg/mL in the control group). At six months, a statistically significant reduction in bacterial overgrowth was shown in the probiotic group as well.

2 Case reports of birth defect associated with deficiency in bariatric surgery patients

The January 2010 issue of SOARD reports on 2 cases of birth defect that appear to have resulted from severe maternal vitamin deficiency after malabsorptive bariatric surgery. The first case was of a baby born at 33 weeks to a 27 year old mother 16 months post-op from a biliopancreatic diversion (BPD). The mother was deficient in vitamin A, D, K, protein, selenium and zinc. The infant was delivered prematurely with multiple defects including bone malformation, cleft palate, facial hypoplasia, and respiratory insufficiency. The baby died at 3 months of age. The second case was of a full-term infant born to a 26 year old mother 11 months post-op from a roux-en-y gastric bypass. The infant was born with multiple defects of bone and cartilage as well as hearing loss which were attributed primarily to maternal vitamin K deficiency. While most of the recent reports of pregnancy after weight loss surgery have been positive in terms of both fetal and maternal health, these cases should remind us that nutritional deficiency in pregnancy can lead to grave results. Both of these patients had been counseled about waiting 18 months to 2 years before becoming pregnant, one even having signed a consent form prior to bariatric surgery. Because of the significant impact that massive weight loss can have on fertility, it is likely that more young, obese women will opt for bariatric surgery to not only improve their overall health, but also to assist with pregnancy. Clinicians and patients alike need to be made aware of the problems that can arise when women who are not adequately nourished become pregnant. Reference: Kang L , Marty D, Pauli RM, Mendelsohn NJ, Prachand V, Waggoner D. Chondrodysplasia punctata associated with malabsorption from bariatric procedures. Surg Obes Relat Dis. 2010 Jan-Feb;6(1):99-101. Epub 2009 May 23. Abstract: Click Here