Jake Dudley
9/02/2014
Dr. Vance
NTD 3300
Questions on Case Study 2: Bariatric Surgery for Morbid Obesity
I.
Understanding the Diagnosis and Pathophysiology
1. Discuss the classification of morbid obesity.
Morbid obesity is a serious health condition that can interfere with basic physical
functions such as breathing or walking. Those who are morbidly obese are at greater risk
for illnesses including diabetes, high blood pressure, sleep apnea, gastroesophageal reflux
disease (GERD), gallstones, osteoarthritis, heart disease, and cancer. Obesity is classified
in accordance to the BMI chart, a BMI of 30-34.9 is class I obesity, 35- 39.9 is class II
obesity and a BMI of >40 is class III obesity and would be considered morbidly obese.
2. Describe the primary health risks involved with untreated morbid obesity. What
health risks does Mr. McKinley present with?
If left untreated, morbid obesity can lead to health risks including type 2 diabetes, high
bloodpressure, lipid abnormalities, hepatobiliary disorders, cancers, reproductive
disorders, breathing problems and premature death. Individuals who are obese are here
times more likely to acquire type 2 diabetes and high blood pressure than individuals of
normal weight. Obese individuals are at greater risks for abnormal lipid profiles, show
higher levels of LDL and total cholesterol levels, and significantly lower serum levels of
HDL Cholesterol. For men excessive fat can cause enlargement of the mammary glad,
hypogonadism, reduced testosterone levels and elevated estrogen levels leading to
reproduction disorders. Women with untreated obesity can also encounter reproductive
disorders due to menstrual abnormalities and polycystic ovarian syndrome. Hepatobiliary
disorders such as nonalcoholic fatty liver disease are also a resulting factor of untreated
obesity. Individuals who are overweight and obese are more likely to experience
breathing problems such as sleep apnea and asthma.
Mr. McKinley’s current health risks including type 2 diabetes, high blood pressure, and
hyperlipidemia. His overall cholesterol is relatively high along with his VLDL, LDL and
LDL/HDL ratio.
3. What are the standard adult criteria for consideration as a candidate for bariatric
surgery? After reading Mr. McKinley’s medical record, determine the criteria that
allow him to qualify for surgery.
In order to be eligible for bariatric surgery a patient must have class III obesity and have
a history of not being able to lose weight by less invasive means. A patient can also be a
candidate for the surgery if they have a BMI greater than or equal to 35, and are
diagnosed with a high-risk health comorbidity. Mr. McKinley is an eligible candidate for
the surgery due to his BMI of 58.8 and his diagnosis of type 2 diabetes mellitus.
4. By performing an internet search or literature review, find one example of a
bariatric surgery program. Describe the information that is provided for the patient
regarding qualification for surgery. Outline the personnel involved in the evaluation
and care of the patient in this particular program.
The Bariatric Sugery Program I found was through Portneuf Medical Center in Pocatello, ID. In
order to qualify as a bariatric patient, patients should have:


100 pounds or more of excess weight; or a BMI of 40 or greater
A BMI of 35 or greater with one or more co-morbid condition
Other common guidelines include:




Understanding the risks of bariatric surgery
Committing to dietary and other lifestyle changes as recommended by the surgeon
Having a history of weight loss treatments having failed the patient
Undergoing a complete examination including medical tests
The personnel involved in the evaluation and care of the patient in this particular
program and the process of approval include:
The qualification process includes a series of tests with your bariatric surgeon. You also will
meet with a nutritionist, psychologist, and other support staff members in sessions leading up to
surgery. Each healthcare professional will help you prepare for the changes and challenges that
lie ahead.
Post-op, you will then meet with the members of the support team who will help to instruct and
guide you on your way to recovery by following the strict guidelines that would be set forth by
the surgeon and team.
5. Describe the following surgical procedures used for bariatric surgery, including
advantages, disadvantages, and potential complications.
a. Roux-en-Y gastric bypass
This type of surgery is the most common malabsorptive procedure as well as the
mostcommon type bariatric procedure. The surgeon begins by creating a small
pouch by dividing the upper end of the stomach , which then restricts food intake.
A secontion of small intestine is then attached to the pouch to allow food to
bypass the duodenum, as well as the first portion of the jejunum. The small
intestine is reconnected 150 cm from the pouch to allow ingested food and
digestive enzymes to mix.
Some advantages of this surgery include: superior weight loss compared to
vertical banded gastroplasty and other surgeries, excellent long-term weight
reduction and resolution or elimination of comorbidities (80% resolution type II
diabetes post surgery), and early/late complication rates are reasonably low,
operative mortality from 0.2-0.9%.
In contrast, disadvantages of this surgical procedure include the potential for
anastomotic leaks and strictures, severe dumping syndrome, and
procedure-specific complications such as distention of the excluded stomach and
internal hernias.
b. Vertical sleeve gastrectomy
Vertical sleeve gastrectomy is a restrictive operation which assists with weight
loss by removing a large portion of the stomach. The newer, smaller stomach is
about the size of a banana, limiting the amount. of food one can eat by making
one feel full after eating small amounts of food. The procedure is performed by
creating 2 to 5 incisions into abdomen. A laparoscope camera and other
instruments needed to perform the surgery are placed through openings and a
camera that is connected to a video monitor to see inside belly. The surgeon then
inserts thin instruments through the other openings, and will remove between
75-85% of the stomach. The remaining portions of stomach are joined together
using staples, creating a long, curved suture along the stomach. The surgery does
not alter any sphincter muscles that move food through the stomach.
c. Adjustable gastric banding (Lap-Band)
Adjustable gastric banding is a restrictive operation, which restricts and decreases
food intake and does not interfere with the normal digestive processes. The
procedures is performed by using a hollow band made of special material that is
placed around the stomach near the bottom of the esophogus. This creates a small
pouch and a narrow passage into the larger remaining portion of the
stomach. This small passage delays the emptying of food from the pouch and
causes a feeling of fullness. The band can be tightened or loosened over time to
change the size of the passage. Initially, the pouch can hold about 1 oz of food
and will later expand to 2-3 oz.
d. Vertical banded gastroplasty
During Vertical banded gastroplasty, the surgeon uses staples and a plastic band
to create a small stomach pouch. Patients are unable to eat large quantities of food
and will notice feelings of fullness. Long-term complications with this operation
sometimes include weight regain, severe acid reflux, and difficulty swallowing
solids for about half of the patients. Some patients often require conversion to a
gastric bypass if they have undergone complications with the procedure.
e. Duodenal switch
Duodenal switch is a malabsorptive operation that restricts both food intake and
the amount of calories and nutrients the patient body absorbs. This procedure
allows a large portion of the stomach to be left intact, including the pyloric valve
that regulates release of contents from the stomach into the small intestine. The
duodenum is divided near the P.valve, and the small intestine is divided as well. A
portion of small intestine that is connected to large intestine is then attached to the
short duodenal segment next to the stomach. The remaining segment of
duodenum connected to the pancreas and gallbladder is attached to the limb closer
to the large intestine. Contents from the two segments that mix into what is called
the common channel, which dumps into the large intestine.
f. Biliopancreatic diversion
Biliopancreatic diversion is a malabsorptive procedure less commonly performed
and involves a distal gastrectomy. Such procedure consists of a sleeve
gastrectomy and duodenoileostomy with a long alimentary limb and a common
channel measuring between 50-100cm. Advantages to this surgery includes
substantial weight loss in most patients, amounting more than 70% beyond 10yrs
post-op, resolution of many obesity-related co morbidities, and may be more
efficient than RYGB or restrictive procedures for class III obese patients. In
addition, biliopancreatic diversion can be used as a secondary procedure in
patients who have failed to lose weight with GBP or other restrictive procedures.
It can also be performed laparoscopically, but is a technically challenging
operation when performed.
Disadvantages to the procedure includes higher postoperative complications and
operative mortality rates slightly higher than other bariatric procedures. In
addition, metabolic complications occasionally require re-operation to lengthen
the common channel
6. Mr. McKinley has had type 2 diabetes for several years. His physician shared with
him that after surgery he will not be on any medications for his diabetes and that he
may be able to stop his medications for diabetes all together. Describe the proposed
effect of bariatric surgery on the pathophysiology of type 2 diabetes. What, if any,
other medical conditions might be affected by weight loss?
The effect of bariatric surgery on the pathophysiology of type 2 diabetes may cause
around 80% remission in his diabetes. Research has shown that the complication of
diabetes slows in the progression of blood sugar for being maintained at normal
values.There are no treatments for diabetes that can achieve as high of an alieviating
effect as surgery, which shows evidence that surgery may be the best treatment for
diabetes in type 2 diabetic patients.
Other conditions that would be affected by the weight-loss include:









II.
Heart disease. Weight loss will not cure heart disease but improvements in other
problems such as high BP, high cholesterol, and diabetes suggest that improvement in
risk for heart disease is very likely.
High blood pressure, high cholesterol
Asthma, respiratory insufficiency
Sleep apnea
Improvement in the patients ability to exercise.
Gastroesophageal reflux disease (GERD)
Gallbladder disease
Low back pain
Any other comobity that can be attributed to high adipose tissue in the body.
Understanding the Nutrition Therapy
7. On post-op day one, Mr. McKinley was advanced to the stage 1 Bariatric Surgery
Diet. This consists of sugar-free clear liquids, broth, and sugar-free Jell-O. Why are
sugar-free foods used?
Sugar free foods are used in order to help prevent Dumping syndrome. This occurs when
food high in fat or sugar moves rapidly through the intestinal pathway resulting in
diarrhea, nausea, cramping, dizziness, sweating, and vomiting, which causes great
distress to many bariatric patients post-op.
8. Over the next two months, Mr. McKinley will be progressed to a pureed-consistency
diet with 6-8 small meals. Describe the major goals of this diet for the Roux-en-Y
patient. How Might the nutrition Guidelines differ if Mr. McKinley had undergone
a Lap-Band Procedure?
In the 2nd stage of the post-op diet, the major dietary goals for a Roux-en Y-patient are to
have an intake of or drink 4-6 ounces of fluid per hour, consume a total of 64 ounces of
fluid food daily, and meet protein goals with liquid protein supplements.
In the 3rd stage he will need to drink 4-6 ounces per hour, still trying for a total of 64 fl oz
per day, meeting protein goals with a combination of liquid protein supplements and
pureed or soft/designated food, about 1-4 ounces of food per meal, he should not eat
more than 4oz per meal, he should only consume the amount of food that is comfortable,
and he could add some of the following foods: cottage cheese (fat-free or low-fat) and
eggs cooked with low fat content.
Lap-Band procedure:
Mr. McKinley would eat pureed liquid foods for only 2-3 weeks post-op. At which point
he could slowly add in soft foods and then regular foods when he feels comfortable to do
so. Once he begins solid foods, he will feel full very quickly because the stomach pouch
holds ~1 tbsp of food at first so he will need to be aware of that. The pouch may become
larger over time, however he should not want to stretch it out more than the physician
advises. When the pouch does become larger, it can hold around 1cup of well chewed
foods which is about a quarter of a normal stomach. He may lose weight quickly in the
first 4-6 months post-op, he may have body aches, feel tired,cold, dry skin, mood
changes, hair loss or hair thinning but these symptoms are normal and should go away as
the body getes used to weight loss. The Lap-Band has a much higher calorie count from
the beginning of post-op than other surgeries.
9. Mr. McKinley’s RD has discussed the importance of hydration, protein intake, and
intakes of vitamins and minerals, especially calcium, iron, and B-12. For each of
these nutrients, describe why intake may be inadequate and explain the potential
complications that could result from deficiency.
Hydration: plenty of fluid helps to transport nutrients throughout body, easily eliminate
waste and maintain both blood pressure and body temp. A minimum of 64fl oz each day
is recommended. All non-carbonated, sugar free liquids, not just water, count as fluid.
Ideally about ½ of the daily fluid intake should come from water. 1cup per hour between
the 6-8 small meals, 6-8 times per day and stop 30-45min before meal to prevent fullness
from liquid. All liquids should be caffeine-free. Refrain from drinking alcoholic
beverages, because after surgery, alcohol is absorbed into the system more quickly than
before, making it sedative and mood-altering effects more difficult to predict and control
than the patient may be used to.
Protein intake:This is the most important nutrient the patient must eat post-op. The
patient needs to eat sources of high-quality, low-fat protein first at each meal to ensure
they are receiving adequate protein. Protein helps heal surgical wounds, maintain and
build muscle mass, make hormones and enzymes, blood clot, maintain blood pressure
control, and maintain a healthy immune system.
Calcium: Patients should begin taking 1000mg of calcium, most easily attained as a
supplement taken twice per day when progressing to soft foods. Dissolveable or
chewable supplements are recommended. Around 2 months into recovery, calcium tablets
may be used, it is important to note that such tablet is best absorbed with food. Calcium
and iron should not be taken together because they interfere with the absorption of one
another and should be taken 2 hours apart from one another. Calcium is necessary to
maintain strong bones and carry out a multitude of important functions. In addition, iron
is needed to help blood vessels move blood throughout the body and help release
hormones and enzymes that affect almost every function within the human body.
Iron: Iron is an important part of many proteins and enzymes in order to maintain good
health. It is essential in the process of oxygen transport all throughout the body. Iron is
essential in the prevention blood disorders such as anemia.
Vitamin B-12: Vitamin B12 is required for proper red blood cell formation, neurological
function, and DNA synthesis.
III.
Nutrition Assesment
10. Assess Mr. McKinley’s height and weight. Calculate his BMI and % usual body
weight. What would be a reasonable weight goal for Mr. McKinley? Give your
rationale for the method you used to determine this.
Mr. McKinley currently weighs 410 lbs and is 5’ 10’’ tall. His BMI is 58.95. Six
months ago Mr. McKinley was at his peak weight of 434 lbs which presents his current
%UBW at 94% Usual body weight, which is due to his pre-op diet as recommended
before surgery.
BMI Calculation:
2.2lbs = 1 kg
(410lbs)(1kg / 2.2 lbs) = 186.364 kg
5’10’’ = 70’’
1’’ = 0.0254m
(70’’)(0.0254m) = 1.778 m
BMI= weight (kg) / height (m)^2
186.364 kg / 1.778 m2= his BMI=58.95
% UBW Calculation:
Current body weight= 186.4 kg
Usual body weight = 197.3 kg
%UBW= [(current body weight) / (usual body weight)] x 100
[(186.4)/(197.3)] x 100=
%UBW= 94%
Using the IBW, an ideal body weight for Mr. McKinley would be 182 lbs. Mr.McKinley
has been over 250lbs since age 15, which leads us to believe he is a large framed
individual. Research states that the calculation for morbidly obese patients can be
estimated quite low and it is generally significantly lower than their Lowest Body Weight
recorded. Therefore the administration of drug dosages based on IBW for morbidly obese
patients can result in under dosages. IBW is indicating that all patients of the same height
receive the same dosage of a medication and fails to account for changes in body
composition associated with morbidly obese patients. In order to properly dose these
patients, research studies show that most morbidly obese patients would receive the
correct dosage if IBW added 40%. If we calculated Mr. McKinley’s IBW and added the
40% he would be receiving drug dosages for a patient of 230 lbs.
11. After reading the physician’s history and physical, indentify any signs or symptoms
that are most likely a consequence of Mr. McKinley’s morbid obesity.
After reviewing Mr. McKinley’s history and physical, some consequences of his obesity
would include hyperlipidemia and type 2 diabetes. Hyperlipidemia is an abnormal lipid
profile that is a consequence of his obesity putting him a risk for heart disease. 80% of
individuals with type 2 diabetes are overweight or obese.
Other consequences of his morbidly obese state would include his history of total right
knee replacement. Mr. McKinley is also has a rash on his abdomen under his folds of
skin, which is most likely due to chafing of his skin and extra fat.
12. Identify any abnormal biochemical indices and discuss the probable underlying
etiology. How might they change after weight loss?
Upon admittance Mr. McKinley had many abnormalities.
Cholesterol (mg/dL) 220
Normal 120-190
HDL-C (mg/dL) 32
Normal >45
VLDL (mg/dL) 45
Normal 7-32
LDL (mg/dL) 232
Normal <130
LDL/HDL ratio 7.5
Normal <3.55
Triglycerides (mg/dL) 245
Normal 40-160
CPK (U/L) 220
Normal 55-170
HbA1c (%)7.2
Normal 3.9-5.2
Potassium (mEq/L) 5.8
Normal 3.5-5.5
Glucose (mg/dL) 145
Normal 70-110
Mr. McKinley’s lab results show rather high levels of overall cholesterol, VLDL levels,
LDL levels, LDL/HDL ratio. These ratio indicate that he is suffering from high
cholesterol and dyslipidemia, which puts him at high risk for heart disease. Mr.
McKinley’s labs also show elevated triglyceride levels, which indicate poorly controlled
diabetes. CPK is an enzyme that is found mainly in the heart, brain and skeletal muscles.
Elevated levels of CPK can indicate an individual with hypothyroidism. A HbA1c (%)
test shows the average level of glucose over the previous three months. This elevated
level is a result of his diabetes and puts him at higher risk for developing problems such
as eye, heart, and kidney disease, as well as nerve damage and stroke. After his bariatric
surgery Mr. McKinley will see a reduction in cholesterol levels and, triglyceride and
reduction is his blood glucose levels. Some patients who undergo bariatric surgery will
have their diabetes go into about 80% remission and will be able rely less on medications
used to treat type 2 diabetes.
13. Determine Mr. McKinley’s energy and protein requirements to promoteweight loss.
Explain the rationale for the Method you used to calculate these requirements.
To promote weight loss, Mr. McKinley should consume between 2000-2500 kcals/day as
he can manage. Calculating his Total Energy Expenditure for obese adults indicates 2589
kcals/ day should be consumed to maintain his weight. As Mr. McKinley recovers, he
will be following a general recommended low calorie diet or LCD. 15% of his daily
calories are to be consumed as protein meaning that Mr. McKinley will be consuming
between 300-375 kcals/ day from protein which amounts to between 75-94 grams.
Total Energy Expenditure (TEE) for Obese Adults
TEE= 1086 – 10.1 x age + PA x (13.7 x weight + 416 x height)
Age = 37 years old
PA = 1.00 for sedentary lifestyle
Weight= 182.6 lbs = 83 kg
Height = 70in = 1.778m
TEE= 1086 – 10.1 x 37 + 1.00 x (13.7 x 83 + 416 x 1.778)
TEE= 2589
Protein:
Estimated calorie range: 2000-2500 kcals/ day
2000 x 15% = 300 kcals protein
2500 x 15% = 375 kcals protein
300 kcals protein x(1 gram protein/ 4 kcals) = 75 grams protein
375 kcals protein x(1 gram protein/ 4 kcals) = 94 grams protein
IV.
Nutrition Diagnosis
14. Identify at least two pertinent nutrition problems and the corresponding nutrition
diagnosis.
Food and nutrition related knowledge deficit related to uncontrolled type-2 diabetes and
morbid obesity as evidence by a BMI of 58.9, elevated triglyceride levels and elevated
blood glucose levels. Physical inactivity related to sedentary lifestyle and a seated
occupation as evidence by a lifelong history of physical inactivity and a BMI of 58.9.
V.
Nutrition Intervention
15. Determine the appropriate progression of Mr. McKinley’s post-bariatric-surgery
diet. Include recommendations for any supplementation that you would advise.
For the first 2 days post-op he will be on a clear liquids diet that is plain or sugar-free and
clear liquids that he could handle. For the following 2 weeks he would be able to have
fluids that include tea, juices diluted with water, low-sodium broth, and sugar free gelatin
or sugar free popsicles. Artificial sweeteners are allowed post-op for Mr. McKinley. The
first month he will gradually move from clear liquids to purees. Foods that have an
applesauce-like consistency. It is important for Mr. McKinley ro eat slowly and always
chew pieces of food very thoroughly. In the next phase, meat and meat-likefoods that are
appropriate consist of eggs, pureed water packed tuna, pureed cooked chicken, fish, etc.,
smooth peanut butter and soy products. Steak and whole food items of the same makeup
will not be reintroduced into the diet until at least 6 months after the surgery. Raw and
uncooked vegetables are restricted for 3 months post surgery. Mr. McKinley will be
advised in this stage to stop drinking 30-45 minutes before any meal and not to consume
liquids again until at least 2 hours after a meal due to the restricted volume that his
stomach can now hold. Meal sizes will have to be small, about ½ cup and should not
exceed 1 cup at any time. Mr. McKinley will be advised to keep a food journal to remain
aware of his food consumption. Recommended supplements after the surgery would
include a multivitamin, a calcium supplement, vitamin B12, and additional iron as
needed.
16. Describe any pertinant lifestyle changes that you would view as a priority for Mr.
McKinley.
Lifestyle changes that may be advised for Mr. McKinley would include a change in diet
and behavioral change to increase physical activity in his everyday life. Eating apropriate
nutrient dense foods will not only help him lose weight, but will also help him control his
diabetes and hypertension. Mr. McKinley will be required to monitor his alcohol intake.
Education of low sodium foods and heart health will be provided to help him make
changes toward a healthier lifestyle. Counseling on his lifestyle changes will help to
prevent any further weight regain or damage.
17. How would you assess Mr. McKinley’s readiness for a physical activity plan? How
does exercise assist in weight loss after bariatric surgery?
To assess Mr. McKinley’s readiness for exercise we must slowly introduce him to low
impact activities that preferrably avoid weight baring nature such as walking or stretching
exercises. Mr. McKinley’s willingness to make the change will be assessed in a
counseling session with his dietitian and he will be provided with proper education and
supervision when introducing him to physical activity. Mr. McKinley will be educated on
the things he can do in his everyday life to increase physical activity level. The benefits
of exercise after bariatric surgery can reduce the risks of premature death, health disease,
diabetes, high blood pressure, colon cancer, depression and anxiety. Exercise can build
and maintain healthy bones, muscles and joints and help control weight.
VI.
Nutrition Monitoring and Evaluation
18. Identify the steps you would take to monitor Mr. McKinley’s nutritional status
postoperatively.
1. Reassess lab values
2. Food Diary upon realease
3. Exercise Diary to recording duration, intensity, type and any information realting to his
physical status post-op.
19. From the literature, what is the success rate of bariatric surgery? What patient
characteristics may increase the likelihood for success?
Most patients will lose about 66 to 80 percent of their excess body weight with a gastric
bypass procedure and proper monitoring. Substantial weight loss generally occurs 18 to
24 months after surgery however it is normal and expected for some weight regain to
occur two to five years after surgery. Proper motivation to pursue an exercise program
post-op and to follow recommended dietary guidelines are necessary for the success of
the patient. In order to increase the likelihood of success, the most powerful tools are
providing knowledge and education of nutrition & exercise. They must be properly
coached in the process of enduring the exercise and healthy diet in order to achieve the
most positive results from bariatric surgery.
20. Mr. McKinley asks you about the possibility of bariatric surgery for a young cousin
who is 10 years old. What are the criteria for bariatric surgery in children and
adolescents?
It is generally not recommended that children under the age of 16 undergo bariatric
surgery unless they are in a life-threatening situation. But first the child must need to fit
the criteria of having a BMI of over 40 or over 35 with comorbidity issues. Prior to
bariatric surgery a psychological evaluation must be performed as well as laboratory
values, a sleep study, cardiology evaluation, bariatric surgery support group, other tests
and evlautions as well as many other requirementes and approval for surgery from a
bariatric surgeon.
21. Write an ADIME note for your inpatient nutrition assessment with initial education
for the Stage 1 (liquid) diet for Mr. McKinley.
● A: Current weight of 410lbs, BMI 58.9, Height 5’10’’, BP 135/90, hypertension, pulse
85, respiratory rate 23, elevated triglycerides of 345 mg/dL, hyperlipidemia, elevated
total cholesterol 320mg/dL, decreased HDL 32 mg/dL, increased LDL of 232 mg/dL,
type 2 diabetes, osteoarthritis, alcohol use 2-3 beers per week
● D: Food and nutrition related knowledge deficit related to uncontrolled type 2 diabetes
and morbid obesity as evidence by a BMI of 58.9, elevated triglyceride levels and
elevated blood glucose levels, physical inactivity related to sedentary lifestyle and a
seated occupation as evidence by a lifelong history of physical inactivity and a BMI of
58.9
● I: Introduction to physical activity plan. Post bariatric surgery support group. Nutrition
education on low sodium diet, adequate energy intake, and healthy fat sources.
● M & E: 1. Reassess lab values 2. Food Diary upon release 3. Exercise Diary to record
duration, intensity, type and related physical status 4. Overall health/wellness and
psychological evaluation of happiness with post-operative program
Resources
Medical Nutrition Therapy : A Case Study Approach. 4th Edition
Nutrition Therapy and Pathophysiology 2nd Edition
Portmed.com
Wikipedia.com
WebMd.com
WHO.int