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Daniel Caesar Returns With Surprise Album ‘Case Study 01’

By Elias Leight

Elias Leight

Daniel Caesar, the balladeer whose serene R&B tracks have been streamed hundreds of millions of times even though he is not signed to a major label, released a new album without warning on Thursday at midnight. Case Study 01  includes contributions from Pharrell Williams and John Mayer. It marks Caesar’s first full-length since 2017’s Freudian .

The album’s first single is “Love Again,” a duet with the golden-voiced R&B veteran Brandy. Leading with this track is a savvy move on Caesar’s part, since duets played a crucial role in his mainstream breakthrough. The singer’s first hit was “Get You,” a tranquil back-and-forth with Kali Uchis. He followed that with the breathy “Best Part,” which performed even better on the charts. Both those tracks were eventually certified platinum by the RIAA; they still get more than 500 combined spins a week at radio to this day. Freudian also contained two more male-female duets — with Syd and Charlotte Day Wilson, respectively.

Caesar has mostly been quiet since  Freudian , content to tour and watch his stream counts pile up. Last year he released “Who Hurt You,” a one-off that hinted at a new direction — this song was lusty and demanding, with a drum tone that evoked Prince. “Strange new addictions picked up on the road/Changed my opinions and changed up my flows,” he sang. That track is not on Case Study 01 . Instead, he sticks closely to the Freudian flows that brought Caesar success on the streaming services and in the radio format known as “Adult R&B.”

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Daniel Caesar, Case Study 01 | Album Review 💿

Published by the musical hype on july 3, 2019 july 3, 2019.

Fresh off of his first Grammy win, Canadian R&B standout Daniel Caesar delivers a strong follow-up to his debut album (‘ Freudian ’) with ‘ Case Study 01 .’

R&B music has hit it fair share of “bumps in the road” over the years, cooling down tremendously over the years.  Regardless, the genre has still managed to have its fair share of bright spots, including Grammy-winning, Canadian standout, Daniel Caesar.   Caesar delivered one of the very best albums, regardless of genre, with his debut LP, Freudian in 2017. Freudian blended themes of love and spirituality superbly.  Since then, the artist has had some missteps , not musically mind you, but socially and culturally .  Focusing on solely on the music, his highly-anticipated follow-up, Case Study 01 , continues the excellence, while bringing in some talented collaborators: Brandy , Pharrell Williams , Sean Leon , Jacob Collier , and John Mayer .

It’s not every album that features a song that references physics, particular a R&B album. Standout ✓ “Entropy” earns that distinction, and Daniel Caesar actually says the word on the chorus of the song:

“Oh, how can this be? I finally found peace Just how long ‘til she’s stripped from me? So, come on, baby, in time we’ll all freeze Ain’t no stoppin’ that entropy .”

Sure, the concept of entropy itself can get technical, but in broad terms, it boils down to “chaos, disorganization, randomness”; a lack of order or predictability.  Within the soulful song, Caesar highlights the unpredictability of life and love. He even manages to fuse science and spirituality on the outro: “Drifting towards the deep freeze / Thermodynamics, there’s no escape / The good Lord he gives, the Lord he takes / No life without energy.”  

The love-centric ✓ “Cyanide” keeps Case Study 01 an intriguing listening experience.  The production remains soulful, benefiting from an old-school Tommy James and the Shondells sample ( “Candy Maker” ).  Also, keeping things fresh, are guest vocals by Toronto rapper Kardinal Offishall , which brings a cool Jamaican element into the picture. As if the first two songs weren’t great in their own right, Brandy joins Caesar for the terrific duet, ✓ “Love Again.” The relationship has ended, yet both seem to be willing to find reconciliation.  Both offer their perspective on where things fell short, offering up a seemingly simple solution: “If you can take my hand / I promise we’ll find love again.”

“Frontal Lobe Muzik”

If “Love Again” was kinder, gentler Daniel Caesar, than he toughens up his sound on “Frontal Lobe Muzik” featuring Pharrell Williams .  Williams sings on the love-centric chorus, while The Neptunes handle production duties.  No, Caesar doesn’t go extremely left of center, but as he did throughout Freudian , he is more profane, uses more slang, and embraces a more ‘street smart’ sensibility.  He still retains an approach idiomatic of R&B, even if it dips into hip-hop without crossing any lines.

✓ “Open Up” is the gospel-tinged slow-jam that R&B lovers definitely need in their lives. That said, there’s nothing ‘spiritual’ about “Open Up,” which finds Caesar being overtly sexual yet also emotionally invested – “The piano that I fuck you on / Same one that on which I write these songs for you.” The big thing he desires from her is to “…Open up to me, girl / Let me plant my seed, girl / Let me fill your needs, girl.”

“Restore the Feeling”  

“Restore the Feeling” brings Sean Leon and Jacob Collier into the mix.  Caesar sings the first verse himself, while Collier joins him on the memorable chorus, adding some smooth harmonies.  Leon sings and raps the second verse, providing a clear contrast to Caesar. The best moment of “Restore the Feeling” is arguably the outro, which expands upon Collier’s awesome contributions.  This is a good song, but arguably, it could use just a slight bit more finesse to make it truly great.

Physics once more enters the mix on ✓ “Superposition” featuring John Mayer .  True to the title, Caesar bases the record itself on the idea/theory of superposition .  It begins from the start, where he sings on the first verse, “Isn’t it an irony? / The things that inspire me / they make me bleed / so profusely.” On the chorus, much like “Entropy,” he directly references superposition:

“Exist in superposition Life’s all about contradiction Yin and yang Fluidity and things I’m me, I’m God I’m everything I’m my own reason why I sing And so are you, are you understanding?”

The second verse is quite deep, highlighted by the lyric, “If I should die before I wake / Oh, please do not resuscitate / I know I didn’t live my life in vain / This music shit’s a piece of cake / The rest of my life’s in a state of chaos…”

“Too Deep to Turn Back”

“So, what’s the price / We’re like mosquitos to light, in a sense / I feed off bioluminescence…” Case Study 01 continues to be complex, yet rewarding project, further evidenced by the lovely “Too Deep to Turn Back.”  If it hasn’t been highlighted, Daniel Caesar sounds fantastic, never needing to ‘break a sweat’ to pack a punch.  Here, religion plays a significant role, specifically on the chorus, which features vocals by Arianna Reid , as well as the fourth verse (“I’ve slept like Jacob, a rock for a pillow / Run swift like Elijah, away from the middle”).     

Two more songs grace Case Study 001 . “Complexities” possesses a lovely backdrop by all means, even if the song itself isn’t as cutting edge or as intriguing as the best of the album.  “Are You Ok?” closes equally lovely, featuring more introspection from Caesar that has characterized the album as a whole.  An instrumental break signals a change of pace, one that finds Caesar addressing ‘Emily’ a couple of times (“Sweet Emily, my bride to be / Struggle with me, if I’d entropy …”) At six-and-a-half minutes it is a bit demanding, but also rewarding in many respects.

Final Thoughts

So, earlier, we said that Freudian was one of the best albums released regardless of genre in 2017.  The same can be said of Case Study 01 , which gives R&B lovers another reason to have faith in the genre.  Furthermore, this particular project gives all music lovers a truly creative and well-rounded album, one with many memorable moments. One thing is for sure – Daniel Caesar is a truly special, truly talented musician. You can argue that the end of the album isn’t quite as punchy as the beginning, but all in all, Case Study 01 has its fair share of excellence.

✓ Gems : “Entropy,” “Cyanide,” “Love Again,” “Open Up” & “Superposition”  

Daniel Caesar •  Case Study 01 • Golden Child Recordings •  Release : 6.28.19

Photo credit : golden child recordings.

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the musical hype

the musical hype aka Brent Faulkner has earned Bachelor and Masters degrees in music (music Education, music theory/composition respectively). A multi-instrumentalist, he plays piano, trombone, and organ among numerous other instruments. He's a certified music educator, composer, and a freelance music journalist. Faulkner cites music and writing as two of the most important parts of his life. Notably, he's blessed with a great ear, possessing perfect pitch.

13 Totally Captivating Songs That Reference Science | Playlist · July 5, 2019 at 12:01 am

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CASE STUDY 01

After Daniel Caesar released his soul-baring debut album, Freudian, tracing his decision to leave home and the church at 17, he became one of R&B’s most promising poets, able to distill spiritual complexities into deceptively simple love songs. Then, he got lost in his own head. “I got pretty depressed,” he tells Apple Music, citing artistic pressure, social media, and the isolation of fame as factors. “For a while, I didn’t want to leave my house.” The thing that ultimately freed him from his creative rut was finding comfort in his own mortality. “Everything dies, everything changes—I had to embrace that,” he says. “To not be so scared of failure.” CASE STUDY 01, his existential follow-up, is denser, headier, and riskier, confronting ideas like good and evil, life and death, loneliness, and God. “I’m drawn to touchy subjects,” he says. “They’re my favorite.” He found he kept circling back to themes of death and spirituality. “I’d been reading a lot about Judaism and Kabbalah and meditation. And I was raised religious, so it’s like my operating system,” he says. “But I also needed to free myself from that—to live.” Once he’d regained some creative confidence, he drafted a fantasy lineup of artists to work with on the new music—Pharrell, Brandy, John Mayer. “These are my heroes,” he says. “People who I never thought I’d ever collaborate with, until the opportunity came up and it was like, ‘Is this really real?’” Even more surprising, perhaps, was the degree to which the studio sessions felt like true artistic exchanges. “There were obviously things I admired about these artists,” he says, “but I realized there were also things they admired about me.” Pharrell was drawn to Caesar’s palette of influences—a mix of gospel, R&B, rock, and soul—while Caesar hoped he’d absorb some of Pharrell’s signature playfulness. “I take myself very seriously,” he says, “and there’s something so childlike and fun about his music.” Similarly, Mayer, his all-time favorite artist, was interested in seeing how Caesar pieced lyrics together: “He liked what I say and how I say it.” “SUPERPOSITION” perfectly marries their mutual love of romantic, tuneful melodies and densely layered production. “I wanted a song that could’ve fit on [Mayer's 2006 album] Continuum,” Caesar says. “But, you know, right on the edge.”

June 28, 2019 10 Songs, 43 minutes ℗ 2019 Golden Child Recordings

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Neonatal Neuro-Critical Care Education

Hypoxic-ischemic encephalopathy learning module: case study 001.

Course Objective: to prevent and identify possible hypoxic-ischemic encephalopathy (HIE) cases in neonates. Course Outcomes: learners will be able to define HIE and apply their knowledge to assess a case study.

Course curriculum

Preventing hypoxic-ischemic encephalopathy.

Before We Begin: Learner Information

HIE Lesson Content

Case Study 001

About this course

• 0 hours of video content

Project Dates March 11, 1993 to March 14, 1993

Project Location Eastern U.S.

Project Description This case contains data from the well-known "storm of the century", which devastated the eastern third of the United States in mid-March 1993.

Data Access for  COMET Case Study 001

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• COMET Case Study 001: The Storm of the Century
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Case Study #001: The Low Wattage-High Voltage Problem

Home > Blog Archive > Category: Case Studies > Case Study #001: The Low Wattage-High Voltage Problem

Case Study #001

This case study was the first of many to come, recorded on May 24, 1996, by Thermal Corporation engineer, Jim Dixon. Over the last fifty years, the great team of Thermal Corporation employees has helped many countless customers with heating applications. One of the byproducts of being an established company is having an extensive library of past solutions to lean on.

A customer sent in the following quote for a cartridge heater :

Diameter: 1/4″ Length: 1-1/2″ Lead Length: 20″ Watts: 75W Volts: 208V

When we entered the quote into our tech sheet program, the program was unable to choose an internal resistance wire for these specific cartridge heater values. This caused us to ask three questions:

• Why is this a problem?
• If the program could pick a wire, why would this probably not be a good heater?
• What would we recommend?

Think About the Formula for Wattage

To begin, think about the formula for wattage.

Wattage = Current x Voltage

Heaters that have low wattage and relatively high voltage are typically a problem. If wattage is low and voltage is high, then what is the current? The current would be very low. How do you make a current very low?

I (Current) = E (Voltage) / R (Resistance) OR R = E / I

If the current is low and the voltage is high, what does R need to be? R needs to be very high. How do you make the resistance high? Think of electricity as water flowing through a heater. What diameter water hose has high resistance to the flow of water? A very small diameter hose will resist the flow of water. Thus, we have to use a very small wire and a LOT of it. In this case, we did not have any wire on hand that was small enough to make this particular case work.

Why Would This Not Be a Good Heater?

This leads into our second question: if we did have a small enough wire, why would this not be a good heater?

Remember that as heaters age, an oxide coating builds up on the surface. Temperature cycling accelerates this. Under a certain set of circumstances, the nickel-oxide will build up a constant rate. At some point, the oxide coating cuts off the path for electricity to flow- just like cholesterol clogging up an artery.

The oxide coating on each wire is the same thickness. So, which size do you think would fail first? If you thought the small wire, then you are correct.

What Would We Recommend?

Now, to address the question of what should be recommended. First of all, to cause the wire size to increase, what needs to be changed and how? The answer is the resistance must decrease.

W = E 2 / R

If W does not change, and R goes down, what happens to E ? E must also go down, as well. This means the customer must go to a lower voltage.

208 Volts , 3 phase power, is common in small industrial plants.

If 208V is a voltage from one hot-line to another hot-line, what is the voltage from a hot-line to the ground?

Line to Ground Voltage = Line to Line Voltage / √3 = 120V

Therefore, wherever there is 208V there is probably 120V, also. If we recommend 120 volts, how much does it help the resistance?

Initially: R = E 2 / W 208 2 / 75 = 577Ω

Now: R = E 2 / W 120 2 / 75 = 192Ω

Thus, resistance is decreased by a factor of 3. This is what we recommended to our customer.

Have a question about a heating application?

Contact the Thermal Corporation engineers! We can help you solve any issue or any question you may have regarding your heating application. Get in touch with us by email at [email protected] , by phone at (800) 633-2962 x152 , or chat with us using the instant chat feature located at the bottom of the page.

Written by Jim Dixon Edited by Shelby Reece and Kyle Otte Date Published: 08.23.2019 Last Updated: 08.23.2019

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Case Study 001: REGEN GAS HEATER Hairpin Heat Exchanger vs. BEM Style Shell and Tube

A Regen Gas Heater is used to help de-water natural gas. Natural gas is normally saturated with water that can cause problems and damage to equipment and components. It’s necessary for the gas to go through a dehydration process. Moisture and hydrocarbons in the gas are absorbed by using dewatering agents or desiccants. When the desiccants become overly saturated with moisture and hydrocarbons, a Regen gas heater or reboiler vaporizes the moisture and hydrocarbons to dry the desiccants.

CASE STUDY 001

The BEM Style S&T Exchanger requires an expansion joint to deal with temperature differentials. When the 1400psi HP gas tubeside leaked into the hot oil shellside, the expansion joint was immediately compromised. In this case study the process plant was shut down due to a safety violation, creating a 5-week loss of production, not to mention rework costs.

The safest and most efficient choice for this service is a Hairpin Heat Exchanger. Our design allows the tubeside to naturally expand and contract with differentials in temperature, therefore, the shellside is not affected by the temperature on the tubeside. Due to its unique design the HPHX is safe and durable for these service conditions.

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• Published: 02 April 2024

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

• Brit Torunn Bechensteen 1 , 2 ,
• Cindhya Sithiravel 3 ,
• Ellen Marie Strøm-Roum 4 ,
• Heidi Kathrine Ruud 2 ,
• Gunnhild Kravdal 3 ,
• Jacob A. Winther 1 &
• Tone G. Valderhaug 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  229 ( 2024 ) Cite this article

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Metrics details

Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.

In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n  = 59 [gastric bypass surgery n  = 26, sleeve gastrectomy n  = 31, missing n  = 2] and controls n  = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).

The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p  < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p  = 0.228) or development of gestational diabetes ( n  = 3 [5%] vs. n  = 7 [5%], p  = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p  < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p  = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p  = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p  = 0.030).

Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Peer Review reports

Obesity is common in women of reproductive age, increasing the risk of several complications for mother and child [ 1 , 2 ]. Maternal metabolism in obesity may reduce the likelihood of successful pregnancy [ 3 ]. Moreover, given that weight loss before pregnancy mitigates the adverse outcomes of pregnancy related outcomes from obesity, bariatric surgery in women of reproductive age in increasing [ 4 , 5 ]. However, although bariatric surgery may reduce the risks of certain obesity related complications in pregnancy, pregnancy after bariatric surgery may carry adverse events such as malnutrition, vitamin deficiencies and inadequate weight gain as well as changes in endocrine and metabolic homeostasis [ 6 , 7 , 8 , 9 , 10 ]. Pregnancy following bariatric surgery has been associated with increased risk of preterm birth, nutritional deficiency and small for gestational age [ 7 , 8 , 11 , 12 , 13 , 14 ]. The causality of these effects are not known, but personalized nutritional counseling during post-bariatric pregnancy has been shown to improve nutrient intake of mothers and may contribute to higher weight of offspring [ 15 ].

There is a growing body of evidence suggesting that maternal nutrition and lifestyle affect fetal growth and development [ 16 , 17 ]. Micronutrients are vitamins and minerals that enable the body to produce enzymes, hormones and other substances essential for normal growth and development [ 18 ]. Micronutrient deficiencies contribute to poor growth, intellectual impairments and increased risk of morbidity and mortality [ 19 ]. Widespread global micronutrient deficiencies exist, with pregnant women and young children at highest risk [ 19 ]. Micronutrient interventions such as supplementation of folate to prevent neural tube defects zinc to reduce risk of preterm birth, and iron to reduce the risk of low birthweight are established [ 20 , 21 , 22 ]. The micronutritional deficiencies seen after bariatric surgery might be explained by poor dietary pattern in combination with gastrointestinal modification and reduced intestinal transit time [ 23 , 24 , 25 , 26 , 27 ]. Deficiencies of fatty soluble vitamins seem to be particularly prevalent in post-bariatric pregnancies, with potential risks of impaired vision, neuronal disorders, impairment of the immune system and hypocoagulability for mother and child [ 24 , 28 , 29 , 30 ].

While sleeve gastrectomy is the most common surgical procedure for the treatment of obesity worldwide, there is conflicting evidence on the optimal surgical procedure before subsequent pregnancy [ 10 , 31 ]. A large registry study showed no difference between gastric bypass and sleeve gastrectomy for preterm birth or small for gestational age [ 12 ]. Studies indicates increased risk of prematurity in pregnancy occurring less than 2 years after bariatric surgery [ 12 , 32 ]. However, other studies have not confirmed increased risks in pregnancies related to time-interval between bariatric surgery and conception [ 13 , 33 ]. As such, there is an evident knowledge gap on the impact of bariatric surgery on micronutrient status in pregnancies as well as outcomes for mother and child in order to provide optimal obstetric care in this group.

The aim of this study was to assess the impact of bariatric surgery on concentrations of micronutrients in post-bariatric pregnancies compared with non-surgical controls. Specifically, we hypothesized that fatty soluble micronutrients, including vitamin K1, was impaired after bariatric surgery. We also wanted to assess differences in maternal micronutrients concentrations following sleeve gastrectomy versus gastric bariatric surgery.

Materials and methods

Design and study population.

This observational case control study compared micronutritional status in pregnancy after bariatric surgery with non-surgical controls. Study participants were recruited from Akershus university hospital, between October 18th 2018 and December 9th 2022. Pregnant women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A total of 59 women with a previous bariatric surgery was included in the study and information on surgical procedure was available for 57 women (gastric bypass surgery n  = 26 and sleeve gastrectomy n  = 31). All women with post-bariatric pregnancies were closely monitored individually by a clinical doctor and a registered clinical dietitian focusing on micronutrient status and gestational weight gain. The controls received standard hospital care and dietary advice with additional advice if the blood samples revealed deficiencies.

A total of 204 women were included in this study with 92% of Caucasian ethnicity ( n  = 185). We compared micronutrient status in pregnancy in women with previous bariatric surgery ( n  = 59) to controls ( n  = 145). Women with known intestinal conditions (i.e. known inflammatory bowel disease, uncontrolled coeliac disease) were not included in the study. The study was approved by the Regional Committee for Medical and Health Research Ethics (reference 25829). All study participants provided written informed consent before study commencement, and the study was performed in accordance with the Declaration of Helsinki [ 34 ].

Definitions

The reference intervals for micronutrients in non-pregnant women and the chosen cut-offs defining micronutrient deficiencies in pregnancy are presented in Table  1 . We defined micronutrient deficiency according to known physiological changes in blood during pregnancy combined with established reference intervals in a non-pregnant population [ 30 , 35 , 36 , 37 ]. Time interval between bariatric surgery and conception was categorized into < 18 and ≥ 18 months.

Data collection

Clinical and laboratory data were retrieved at mean gestational week 20.4 (SD 4.5) (Bariatric surgery 23.9 [6.5] vs. controls 19.0 [2.0] weeks, p  < 0.001). Follow-up blood sample was available in a subgroup of 32 women with post-bariatric pregnancies at mean 30.4 (SD 5.6) gestational week. All patients completed a questionnaire on comorbidities, medications and dietary supplements. Additional information including maximum weight, time of bariatric surgery, type of bariatric surgery was retrieved during the first visit.

Blood samples and analysis

The blood samples were obtained by venipuncture and collected in Vacuette® tubes. EDTA tubes were used for analysis of hemoglobin, hemoglobin A1c and thiamine (vitamin B1). Lithium heparin gel tubes were used for analysis of zinc and selenium, and serum gel tubes for the remaining analyses. All the blood samples were non-fasting. After blood collection, all tubes were handled according to established procedures. The standard clinical chemistry parameters were analysed at the laboratory at Akershus University Hospital. Hemoglobin was analysed on Sysmex instruments (Sysmex Corporation, Kobe, Japan) and hemoglobin A1c on Tosoh instruments (Tosoh Corporation, Tokyo, Japan). Magnesium and homocysteine were analysed on Vitros 5.1 FS (Ortho Clinical Diagnostics, Raritan, NJ) until May 2021, thereafter on cobas c503 (Roche Diagnostics, Mannheim, Germany). Folate, cobalamin, ferritin and vitamin D were analysed on cobas e801 (Roche Diagnostics). Zinc and selenium were analysed using inductive coupled plasma – mass spectrometry (ICP-MS) and methylmalonic acid (MMA) with a liquid chromatography – mass spectrometry method (LC-MS/MS). Thiamine, pyridoxal 5-phosphate (vitamin B6), vitamin A and vitamin E were analysed at Oslo University Hospital, Aker and vitamin K1 was analysed at Fürst Medical Laboratorium, Oslo, all with chromatographic methods.

Statistical analysis

We estimated that the prevalence of micronutrient deficiency would be 30% in post-bariatric pregnancies and 5% in controls. To confirm a similar difference with a statistical power of more than 80% and a significance level (α) of 0.05, a total of 200 patients had to be included in the study with a 4:1 ratio of cases vs. controls (40 post-bariatric pregnancies and 160 controls). Proportions are reported as numbers with percent, continuous variables as mean ± standard deviation (SD) as appropriate. Differences between treatment groups were analysed using Pearson’s chi-square test or Fishers exact test for categorical data and Student’s t-test for continuous data. Paired sample t-test was used to assess paired observations of micronutrients in baseline and follow-up blood samples. Skewed distributed data were log-transformed to achieve normal distribution. Correlations between possible confounders and vitamin K1 variables were assessed by Spearman’s correlation (rho). Two-sided P values < 0.05 were considered statistically significant. The Bonferroni Holm correction was applied to mitigate the risk of type 1 statistical error. We used linear regression analyses to explore possible associations between bariatric surgery and vitamin K1 and logistic regression analyses to explore possible associations between bariatric surgery and vitamin K1 deficiency. Possible confounders were identified using a stepwise selection approach in which variables with p-values below 0.10 were included along with clinically significant confounders. Coefficients and odds ratio (OR) from regression analysis are presented with 95% confidence interval (CI). The analyses were performed using IBM SPSS Statistics (version 729.0.0).

We included 204 women in the study (bariatric surgery n  = 59 and controls n  = 145). Data on the specific type of surgical procedure were available for 57 women who had undergone bariatric surgery prior to conception (gastric bypass surgery n  = 26 and sleeve gastrectomy = 31). The women in the surgical group lost on average 39.0 (16.9) kg from the time of surgery to the start of pregnancy and the time interval from bariatric surgery to pregnancy was mean 63.7 (39.2) months. Patients’ characteristics by surgical status are presented in Table  2 .

The women with bariatric surgery had a higher pre-pregnant body mass index (BMI) compared with controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m 2 , p  < 0.001). There was no difference between groups regarding age (32.1 [5.7] vs. 31.2 [4.2] years, p  = 0.215), maternal weight gain (13.3 [9.6] vs. 14.8 [6.5] kg, p  = 0.228), HbA1c (30.2 [7.1] vs. 31.1[3.6] mmol/mol, p  = 0.234) or development of gestational diabetes (5% vs. 5%, p  = 1.000). Fewer women with bariatric surgery had completed higher education and more women with bariatric surgery currently smoked compared with controls (24 [43%] vs. 103 [72%], p  < 0.001 and 5 [9%] vs. 0, p  = 0.001, respectively. Children of post-bariatric pregnancies had lower gestational age and lower birthweight, however neither reached statistical significance (38.5[3.1] vs. 39.3[2.1] weeks, p  = 0.054 and 3363 [624] vs. 3520 [521] g, p  = 0.081, respectively).

Dietary supplements and micronutrient status by surgical status are presented in Table  3 . Concentrations of ferritin, magnesium, pyridoxal 5-phosphate, vitamin A, E and K1 and selenium were significantly lower post-bariatric pregnancies compared with controls. Using micronutrients as categorical variables (deficiency yes/no) conferred a higher prevalence of micronutrient deficiencies such as iron, magnesium, pyridoxal 5-phosphate, vitamin K1 and selenium in pregnancies after bariatric surgery compared with controls and a higher prevalence of vitamin K1 deficiency after gastric bariatric surgery vs. sleeve gastrectomy (Fig.  1 ). The distribution of vitamin K1 concentrations in women with post-bariatric pregnancies and controls is presented in Fig.  2 . Paired sample t-test showed increased concentrations vitamin K1 in a subgroup of women with post-bariatric pregnancies (0.29 [0.29] ng/mL to 0.64 [0.92] ng/mL, p  = 0.070).

Micronutritional deficiency in pregnancy. A : pregnancy following bariatric surgery vs. non-surgical controls. B : pregnancy after gastric bypass surgery vs. sleeve gastrectomy. * denotes statistically significance after corrections for multiple comparisons

Distribution of vitamin K1 concentrations in women with post-bariatric pregnancies and controls

The women with gastric bariatric surgery underwent surgery at a younger age and with a longer time-interval between surgery and conception compared with the women with sleeve gastrectomy (23.5 vs. 27.5 years, p  = 0.002 and 85 [40] vs. 45 [28] months, p = < 0.001, respectively). One woman (4%) after gastric bariatric surgery and five women (16%) after sleeve gastrectomy, p  = 0.205 became pregnant < 18 months after surgery. Both surgical groups had lost comparable weight since surgery (gastric bypass surgery 41.4 [17.1] vs. sleeve gastrectomy 37.0 [16.8] kg, p  = 0.342) and they had comparable pre-pregnant BMI (gastric bypass surgery 31.9 [5.5] vs. sleeve gastrectomy 29.9 [6.4] kg/m 2 , p  = 0.222). The proportion of women with vitamin K1 deficiency was higher after gastric bariatric surgery compared with sleeve gastrectomy (gastric bypass surgery 9 [38%] vs. 1 [3%], p  = 0.003 and Fig.  1 ).

Univariate linear regression analysis showed that bariatric surgery was inversely associated with vitamin K1 levels (B -0.33 [95% CI -0.51, -0.15, p  < 0.001]. The result remained statistically significant after multivariable adjustments (-0.26 ng/mL [-0.51, -0.04], p  = 0.047) (Table  4 A). In addition, compared with sleeve gastrectomy, gastric bariatric surgery was inversely associated with vitamin K1 in univariate linear regression analysis (0.20 [0.019, 0.387], p  = 0.031), but not after multivariate adjustment (Table  4 B). Using vitamin K1 as a categorical variable (deficiency yes/no), bariatric surgery was associated with a fivefold increased risk of vitamin K1 deficiency compared with controls and that gastric bariatric surgery was associated with higher adjusted risk of vitamin K1 deficiency compared with sleeve gastrectomy (Table  5 ).

In this study, we compare micronutrient concentrations in post-bariatric pregnancy with matched non-surgical controls. The study shows that the concentrations of vitamin K1, magnesium, and selenium were significantly impaired in post-bariatric pregnancies vs. controls. Moreover, our results show that bariatric surgery was consistently associated with vitamin K1 levels, both as a continuous outcome variable and as a categorical variable (vitamin K1 deficiency) in post-bariatric pregnancy compared with controls. Moreover, the associations might be driven by gastric bariatric surgery rather than sleeve gastrectomy. However, the number of pregnant women with vitamin K1 concentration below the lower reference limit was overall small and the confidence intervals were large. Thus, these results should be interpreted with caution.

Maternal nutrition and micronutrients in pregnancy after bariatric surgery

In pregnancy, there is an increased need for nutrients to support fetal and placental growth and development [ 20 ]. A detailed dietary information was not available in this study and we cannot exclude that the women with bariatric surgery had a different nutritional composition compared with controls. In a subgroup of women with post-bariatric pregnancies, an increment in vitamin K was seen. However, the changes did not reach statistical significance. Follow-up blood samples for the controls were not available. A healthy diet after bariatric surgery may differ from the general population in the composition of lean protein, fruits and vegetables and starchy carbohydrates. Nonetheless, the combination of diet, intestinal modifications and increased metabolism in pregnancy might explain the deficiencies in fatty soluble vitamins seen in this study [ 23 , 24 , 25 , 26 , 27 ]. Improved nutrient intake of mothers was seen after personalized nutritional counseling during post-bariatric pregnancy and might contribute to higher birth weight of offspring [ 15 ]. Given the complexity and heterogeneity of nutritional status in post-bariatric pregnancies, focusing on sub-groups including pre-gestational nutritional deficiencies, and type of surgery performed is of vital importance. A recent consensus report recommended specialized care in pregnancies after bariatric surgery [ 38 ]. There is however a paucity of data to support clinical practice [ 38 , 39 ]. As such, there is an imperative need to identify pregnancy and trimester specific reference intervals and clinical decision limits in order to help clinical advice on dietary supplement.

Lifelong dietary supplement is recommended after bariatric surgery, however adherence to adequate dietary supplements seems to decrease over time [ 26 , 40 , 41 ]. Our study also confers inadequate use of dietary supplements in pregnancy after bariatric surgery with 30–70% of the women not taking recommended post-bariatric surgery dietary supplements (Table  3 ). Thus, a need for increased awareness to ensure adequate microntutrional care before, during and after pregnancy is imperative.

The role of vitamin K1 in pregnancy after bariatric surgery

In line with our results, a systematic review on vitamin K1 concentrations in patients with a history of bariatric surgery reported high risk of vitamin K1 deficiency after bariatric surgery and opted for better monitoring [ 23 ]. Our results also cohere with another study of 49 pregnant women with previous bariatric surgery, showing that vitamin K1 concentrations were lower in women with a history of bariatric surgery compared with 27 controls [ 30 ]. The increased fat storage in pregnancy may lead to less bioavailability for activation of fatty soluble vitamins [ 42 ]. Furthermore, the highly fat-soluble vitamin K1 depend upon conjugated bile salts for adequate absorption. Consequently, reduced stomach acid production, reduced absorption surface and shorter interaction time between conjugated bile salts and vitamin K1 might explain the lower serum concentrations of vitamin K1 after bariatric surgery [ 43 ]. Screening for vitamin K1 deficiency is usually recommended after malabsorptive surgical procedures including biliopancreatic diversion with or without duodenal switch [ 43 ]. However, restrictive procedures may also cause vitamin deficiencies due to digestive symptoms such as vomiting and food intolerance. Interestingly, lower levels of vitamin K1 were found in the first trimester compared to a control group of women without bariatric surgery [ 30 ]. Vomiting and food intolerance may also be the main symptoms of hyperemesis gravidarum, which calls for increased vigilance of vitamin K1 insufficiency in post-bariatric pregnancies in women with symptoms of hyperemesis in pregnancy.

The impact of vitamin K1 deficiency in post-bariatric pregnancies is not clear. Low circulating levels of vitamin K1 might lead to a hypocoaguble state in mother and child [ 30 ]. Some cases of neonatal intracranial bleeding have been reported, possible due to vitamin K1 deficiency [ 44 ]. Another study reported that obesity had stronger impact on hypercoagulability than pregnancy itself [ 45 ]. Nonetheless, insufficient data exist in order to recommend interventions of vitamin K1 deficiency in post-bariatric pregnancy [ 38 ]. While optimal monitoring of vitamin K1 during pregnancy following bariatric surgery remains unclear, a major concern is raised about the consistent finding of vitamin K1 deficiency in post-bariatric pregnancy.

Bariatric surgery before pregnancy: timing and selection of procedure – dose it matter?

Few studies have assessed the impact of different surgical procedures before pregnancy. One study of 119 pregnant women found no effect of maternal weight gain on maternal and perinatal outcome after sleeve gastrectomy [ 46 ]. However, the study did not include pregnancies after gastric bariatric surgery for comparison. Another retrospective observational study showed no differences between gastric bariatric surgery and sleeve gastrectomy regarding re-interventions or obstetric outcomes [ 4 ]. Conflicting evidence exists on the possible adverse effects of sleeve gastrectomy such as dyspepsia and weight regain as compared with gastric bariatric surgery [ 47 , 48 , 49 ]. Our study adds important knowledge about the different surgical procedures, suggesting that gastric bariatric surgery holds greater risk of vitamin K1 deficiency compared with sleeve gastrectomy. The optimal surgical procedure for obesity treatment in women of reproductive age is however not clear and a person-centered approach should be advocated in future guidelines.

The timing of pregnancy after bariatric surgery is moreover under debate. Current recommendations suggest waiting at least 12 months after bariatric surgery before planning a pregnancy [ 12 , 38 , 50 ]. In our study, women with previous sleeve gastrectomy had a shorter time interval between surgery and conception than the women with gastric bariatric surgery. This might reflect that the women who underwent gastric bariatric surgery underwent surgery in an era where gastric bariatric surgery was the most common surgical procedure for weight loss [ 31 ]. Interestingly, after adjustments for the time interval since bariatric surgery, gastric bariatric surgery was not associated with vitamin K1 in the linear regression model (Table  4 B). Thus, as adherence to dietary supplements is reduced with time after bariatric surgery, we cannot rule out that patient’ adherence to dietary supplement might have influenced the differences between surgical procedure seen in the present study [ 26 , 40 , 41 ]. On the other hand, the time interval between sleeve gastrectomy and conception did not impact maternal and neonatal outcomes in a study of 15 women conceived > 18 months after surgery. The authors concluded that pregnancy after sleeve gastrectomy was overall safe and well-tolerated [ 33 ]. Furthermore, a study of 30 women who became pregnant within a mean time of 17 months after gastric bariatric surgery did not appear to confer any serious risks in pregnancy with 90% of the children were born at term with normal birthweight [ 13 ]. In our study, only six patients (11%) became pregnant earlier than 18 months after surgery and the study was not designed to assess pregnancy or birth related complications.

Future implications?

The results of this study underscore the need for increased awareness of nutritional and microntutrional status to ensure adequate obstetric care both before and during post-bariatric pregnancies. Also, this study present important information on adherence to dietary supplement that should be considered in the planning of post-bariatric pregnancies. Moreover, the results of our study rises important questions on the impact of micronutrients deficiencies on future child development.

Strengths and limitations

The strengths of this study include the prospective design with matched controls. Moreover, definitions for the chosen cut-offs for micronutrient deficiency were chosen according to pregnancy specific reference intervals if established. However, we cannot rule out that the concentrations of the micronutrients change in pregnancy. Thus, the validity of the chosen cut-offs for defining micronutrient deficiency should be assessed in future studies. This study was a small single center study and did not have the statistical power to assess pregnancy related or birth related complications. The majority of the women in this study was Caucasian and the results may not be valid in populations of other ethnicities. The observational design does not provide any causality between variables. Also, we cannot rule out if the difference in gestational week for blood sampling or non-fasting blood samples might have influenced the micronutrient analyses. Finally, use of dietary supplements was self-reported and we cannot be sure that all the study participants adhered with the recommendation.

This study shows that concentrations of the micronutrients vitamin K1, magnesium, and selenium were significantly impaired in post-bariatric pregnancies compared with controls. We found a negative association between bariatric surgery and vitamin K1 and a higher risk of vitamin K1 deficiency after gastric bariatric surgery compared with sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be assessed in future studies.

Data availability

The data used in the present study is not open access or publicly available. The datasets are available from the corresponding author on reasonable request.

Abbreviations

Body mass index

Confidence interval

Standard deviation

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Acknowledgements

We acknowledge the work of the staff at the Section for Morbid Obesity at Akershus University Hospital HF for the persistent effort of data collection.

No funding was received for conducting this study.

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Department of Endocrinology, Akershus University Hospital HF, Lørenskog, Norway

Brit Torunn Bechensteen, Jacob A. Winther & Tone G. Valderhaug

Department of Clinical nutrition, Akershus University Hospital HF, Lørenskog, Norway

Brit Torunn Bechensteen & Heidi Kathrine Ruud

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Cindhya Sithiravel & Gunnhild Kravdal

Department of Gynecology, Akershus University Hospital HF, Lørenskog, Norway

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TGV and EMRS designed the study. BTB, EMRS and TGV collected the data for the study. TGV analysed the data. BTB and TGV drafted the manuscript. CS ad GK were responsible for the laboratory analyses. TGV and JAW were responsible for the statistical analyses. All authors contributed to the interpretation of data, reviewed and edited the manuscript and gave their final approval of the final version to be published.

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Correspondence to Tone G. Valderhaug .

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The study was approved by the Regional Committee for Medical and Health Research Ethics (reference 25829). The study was performed in accordance with the Declaration of Helsinki. All study participants provided written informed consent to participate in the study.

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Not applicable.

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The authors declare no competing interests.

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Bechensteen, B.T., Sithiravel, C., Strøm-Roum, E.M. et al. Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study. BMC Pregnancy Childbirth 24 , 229 (2024). https://doi.org/10.1186/s12884-024-06407-0

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Received : 19 October 2023

Accepted : 11 March 2024

Published : 02 April 2024

DOI : https://doi.org/10.1186/s12884-024-06407-0

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