Maternale obesitas en bariatrische heelkunde - de focus op nutritionele status en voeding

Background: Maternal obesity is a prevalent public health concern worldwide. Behavioral lifestyle interventions are the first treatment option in pregnancy, although they have limited results on clinical outcomes. In a search for an alternative, the promotion of bariatric surgery in the pre- or inter-pregnancy is now being considered. At this moment, an adequate maternal nutritional status, the maternal mental wellbeing, and the safety of breastfeeding practices are doubted. Objectives: We aimed 1) to study the effectiveness of a behavioral lifestyle intervention in obese pregnant women for improvements in gestational weight gain and glucose metabolism, 2) to examine the maternal nutritional status in pregnancy following bariatric surgery, 3) to compare levels of anxiety and depression in pregnant women with a history of bariatric surgery with pregnant obese women, taking into account the dietary intake of n-3 and n-6 fatty acids, folate and vitamin B-12, and 5) to study the breast milk composition in obese women and women with previous bariatric surgery in the first six weeks of lactation. Methods: The behavioral lifestyle intervention in obese pregnant women was examined as part of a European randomized controlled study. Furthermore, we performed longitudinal prospective (controlled) cohort studies in pregnancy and postpartum of women with a history of bariatric surgery. Results: The behavioral lifestyle intervention in obese pregnant women was effective to establish dietary and physical activity improvements, notwithstanding these were too subtle to mediate improvements in gestational weight gain, fasting glucose and HOMA-IR concentrations. On the other hand, pregnancy following bariatric surgery was characterized by depleted and deficient maternal concentrations of in particular vitamin A, 25-OH-D, B-12 and K1, albumin, ferritin and hemoglobin, both in the restrictive and malabsorptive procedures. A patient-tailored supplementation strategy only partially restored maternal concentrations. Pregnant women with previous bariatric surgery were more anxious during the course of pregnancy than obese pregnant women, what could not be explained by an inadequate maternal diet. Given the impaired nutritional status and poor dietary habits shown in pregnant women with bariatric surgery, no different milk macronutrient, energy and vitamin A composition was found when comparing to non-surgical controls of different BMI categories. Discussion and conclusion: The limited effects of behavioral lifestyle interventions in obese pregnant women were confirmed. Therefore, bariatric surgery in the pre- or inter-pregnancy period seems an acceptable alternative. Importantly, conditions for a healthy pregnancy following bariatric surgery include a standard approach for screening of nutritional deficiencies before, during and after pregnancy and a patient-tailored supplementation strategy. Furthermore, patient counseling with attention for a healthy lifestyle and mental wellbeing should be standard of care and breastfeeding should be promoted because of its range of benefits for both mother and child.ABSTRACT OF THE PHD THESIS 1.GENERAL INTRODUCTION AND OBJECTIVES 1.1 GENERAL INTRODUCTION 1.2 GENERAL HYPOTHESIS, AIMS AND OUTLINE OF THE THESIS 2. DIET AND LIFESTYLE INTERVENTION IN OBESE PREGNANT WOMEN 2.1 A DIET QUALITY INDEX FOR EUROPEAN OBESE PREGNANT WOMEN: DEVELOPMENT AND RELATIVE VALIDITY 2.2 DO PHYSICAL ACTIVITY AND DIETARY CHANGES MEDIATE EFFECTS OF A LIFESTYLE INTERVENTION ON GESTATIONAL WEIGHT GAIN AND GLUCOSE METABOLISM? FINDINGS FROM THE DALI RANDOMIZED CONTROLLED TRIAL 3. NUTRITIONAL STATUS IN PREGNANCY FOLLOWING BARIATRIC SURGERY 3.1 MATERNAL MICRONUTRIENT DEFICIENCIES AND RELATED ADVERSE NEONATAL OUTCOMES IN PREGNANCY FOLLOWING BARIATRIC SURGERY: A SYSTEMATIC REVIEW 3.2 MICRONUTRIENT LEVELS AND SUPPLEMENT INTAKE IN PREGNANCY AFTER BARIATRIC SURGERY: A PROSPECTIVE COHORT STUDY 3.3 VITAMIN K1 MONITORING IN PREGNANCIES AFTER BARIATRIC SURGERY: A PROSPECTIVE COHORT STUDY 4.MENTAL HEALTH IN PREGNANCY FOLLOWING BARIATRIC SURGERY 4.1 DEPRESSION AND ANXIETY IN PREGNANCIES AFTER BARIATRIC SURGERY: THE ROLE OF AN INADEQUATE DIET 5.BREAST MILK COMPOSITION IN OBESE WOMEN AND WOMEN WITH A HISTORY OF BARIATRIC SURGERY 5.1 BREAST MILK MACRONUTRIENT COMPOSITION AFTER BARIATRIC SURGERY 5.2 BREAST MILK COMPOSITION IN OBESE WOMEN AND WOMEN WITH A HISTORY OF BARIATRIC SURGERY: A PROSPECTIVE CONTROLLED LONGITUDINAL STUDY 6. GENERAL DISCUSSION 6.1 GENERAL DISCUSSION AND METHODOLOGICAL CONSIDERATIONS 6.2 CLINICAL RECOMMENDATIONS AND FUTURE PERSPECTIVES SUMMARY SAMENVATTING LIST OF ABBREVIATIONS DANKWOORD CURRICULUM VITAE PUBLICATIONSnrpages: 250status: publishe