DFM 484: Medical Nutrition Therapy I

Case Study #2 Bariatric Surgery for Morbid Obesity

Group: Sarah Schneider, Julie Shimko, Joli Bennett
1. Define BMI for classification of obesity. What BMI is associated with morbid obesity?
Classification of obesity:
Obesity (Class 1): 30.0 34.9 kg/m
Obesity (Class 2): 35.0 39.9 kg/m
Extreme obesity (Class 3): 40 kg/m
A BMI of 40 or greater, or a BMI of 35 or greater (obesity class 2) along with an obesity-related
health condition (such as type 2 diabetes mellitus and hypertension) is associated with Morbid
Obesity.
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Individuals with morbid obesity have a greater risk for developing health conditions such as type
2 diabetes mellitus, heart disease, cancer (endometrium, breast, prostate, and colon),
hypertension, lipid abnormalities (High: LDL-cholesterol, triglycerides; Low: HDL-cholesterol),
breathing problems (such as sleep apnea), arthritis, and reproductive complications (such as
menstrual abnormalities, infertility, polycystic ovarian syndrome, and gestational diabetes).
2. List 5 health risks involved with overweight/obesity.
Health risks involved with overweight and obesity are type 2 diabetes mellitus, hypertension,
coronary heart disease, lipid abnormalities (such as hyperlipidemia), and cancers of the
endometrium, breast, prostate, and colon.
Mr. McKinleys health risks are type 2 diabetes mellitus, hyperlipidemia, hypertension, and
osteoarthritis.
3. What are the standard adult criteria for consideration as a candidate for bariatric
surgery? After reading Mr. McKinleys medical record, determine the criteria that allow
him to qualify for surgery.
Individuals qualifying for bariatric surgery must have a BMI of 40 or greater, or a BMI of 35 or
greater along with obesity-related comorbid conditions. They have to have the motivation to lose
weight, and prior behavioral treatment (with or without pharmacotherapy) has failed.
Mr. McKinley meets all of the criteria for bariatric surgery. His BMI is greater than 40 (BMI: 59)
and his weight loss motivation is reflected in his successful prior weight loss attempts, such as
losing up to 75 pounds and his preoperative weight loss of 24 pounds. However, his past inability
to maintain weight loss indicates his difficulties sustaining behavioral changes.
7.
a. How does the Roux-en-Y procedure affect digestion and absorption?
The Roux-en-Y gastric bypass procedure (RYGB) uses a combination of restriction and
malabsorption to reduce calorie absorption. It reduces the stomach to a small upper pouch, which
is connected by the roux limb to the jejunum thus bypassing the duodenum. The rest of the

stomach is connected by the biliopancreatic limb, which carries gastric juice, bile, and pancreatic
juice, to the jejunum.
The RYGB procedure decreases food intake and bypasses parts of the stomach and duodenum
thus increasing the risk for maldigestion and malabsorption. Because food is transported through
the roux limb, the roux limb prevents the mixing of the food with digestive enzymes and other
components (such as HCl) of digestion. With less HCl secreted in the stomach, intrinsic factor is
less active, which decreases vitamin B12 absorption. A decreased protein digestion decreases
protein absorption resulting in an increased risk for protein malnutrition. Vitamin and mineral
absorption are impaired as food bypasses the duodenum, the major site for vitamin and mineral
absorption. Therefore, RYGB-patients are at increased risk for deficiencies in protein, fat-soluble
vitamins (A, D, E, K), vitamin B12, folate, iron, copper, and calcium.
b. 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 to prevent dumping syndrome a common condition that can develop
after gastric surgery. It occurs when food with a high osmolarity, such as sugar, moves rapidly
from the stomach to the small intestines causing symptoms of dizziness, sweating, decreased
blood pressure, and diarrhea.
8. Over the next 2 months, Mr. McKinley will be progressed to a pureed-consistency diet
with 68 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?
For the first 6 weeks after surgery, he will need to eat a pureed and liquid diet. For several weeks
after surgery, the staple line created in the stomach will be swollen and healing. The patient will
need to consume a liquid diet and pureed foods to allow the stomach to heal correctly. If solid
food is eaten, there is a chance that food particles can get stuck in the opening between the
staples and cause an infection. Adequate protein is important to ensure healing and recovery.
Since the stomach will be reduced drastically in size, the amount of food the patient will be able
to eat at one time will be very limited, so he will need to eat 68 smaller meals instead of 3 larger
meals throughout the day. The patient should slowly progress to solid foods.
If the patient had gone through the lap-band procedure, similar dietary advice would be
provided; however, the patient may be able to progress to soft foods sooner than if had
undergone Roux-en-Y procedure since the Lap-Band procedure is less invasive. Meals high in
energy and protein should be consumed to support the body during the healing process.
9. Mr. McKinleys RD has discussed the importance of hydration, protein intake, and
intakes of vitamins and minerals, especially calcium, iron, and B12. For each of these
nutrients, describe why intake may be inadequate and explain the potential complications
that could result from deficiency.
The upper part of the small intestine, the duodenum, is bypassed in the Roux-en-Y procedure,
which can cause some nutrient deficiencies since some vitamins and minerals are not absorbed.

B12 deficiency is possible because the amount of HCl created in the stomach will be limited.
With limited HCl, intrinsic factor will be deficient, and intrinsic factor is needed for the
absorption of B12.
Iron deficiency is also a possibility after Roux-en-Y, due to the bypassing of the first portion of
the small intestine, low dietary intake, as well as limited absorption due to a decrease of HCl in
the stomach, which is needed for absorption.
Calcium deficiency is due to a large portion of the small intestine being bypassed. Also, calcium
intake may be low after surgery due to the possibility of dumping syndrome. High-fat foods,
including high-fat dairy products are discouraged.
10. Assess Mr. McKinleys 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.
Height: 510= (5 x 12) + 10= 70 x 2.54= 178 cm (1.78 m)
Weight: 410 lbs/2.2lbs/kg= 186 kg
BMI: 186kg/(1.78m x 1.78m)= 59 BMI: 59 kg/m2
% usual body weight= actual weight/usual weight x 100= 410/434 x 100= 94% (% of usual body
weight)
Mr. McKinley has a BMI of 59. Based on his BMI, he is in the category of extreme obesity
(Class III: 40 kg/m2). He currently weighs 410 pounds, which is 94% of his usual weight of
434 pounds; he has lost 24 pounds in the 6 months prior to weight-loss surgery. Research shows
that on average, individuals have lost around 2035% of their initial weight at 2 to 3 years after
bariatric surgery. Based on Mr. McKinleys initial weight of 410 pounds, he should be able to
lose 82 to 143 pounds at 2 to 3 years after surgery. If he loses 143 pounds, then his weight goal
would be around 267 lbs. at 3 years post-op, which would be a 35% weight loss.
11. After reading the physicians history and physical, identify any signs or symptoms that
are most likely a consequence of Mr. McKinleys morbid obesity.
Signs or symptoms which are more likely a consequence of patients morbid obesity:
Ecchymosis (a discoloration of the skin resulting from bleeding underneath), abrasions,
petechiae on lower extremities (a small red or purple spot caused by bleeding into the skin), 2 +
pitting edema (slight indentation of skin; takes 15 seconds to rebound), diminished pulses
bilaterally, obese abdomen, rash present under skinfolds, and blood pressure 135/90.
13. Determine Mr. McKinleys energy and protein requirements to promote weight loss.
Explain the rationale for the method you used to calculate these requirements.
I am using the Harris-Benedict formula to calculate Mr. McKinleys REE (Resting Energy
Expenditure). Since his BMI is in the obese range, Im using his Ideal Body Weight instead of
his actual weight for both the Harris-Benedict & protein calculations.

IBW (Ideal Body Weight) = 106 lbs + 10 (6) = 166 lbs

166/2.2 = 75.5 kg

IBW weight = 75.5 kg, height = 178 cm, age = 37

REE for males = 66.5 + 13.8 weight in kg + 5.0 height in cm 6.8 age in years
REE = 66.5 + (13.8)(75.5) + (5.0)(178) (6.8)(37)
REE = 1747 kcal/day
I would multiply the REE times an activity factor of 1.2 to begin with.
1747 x 1.2 = 2096 kcal/day
One pound of weight equals approximately 3,500 calories. In order to lose 1 pound per week, he
will need to consume 500 fewer calories per day.
In order to lose 1 pound per week, his caloric intake should be 2096500 = 1596 kcal/day.
When he begins to exercise, the calories burned through exercise can be deducted from the 500
calories. For example, if he walks long enough to burn 250 calories, his caloric intake that day
can be 2096250 = 1846.
Protein intake is also based on IBW, rather than actual weight. The standard formula is 0.8 g
protein per kg body weight. However, due to the fact that he is recuperating from surgery, and
the fact that he is trying to gain muscle, I would increase that to 1.0 g protein per kg body
weight. The additional protein helps with satiety as well, and since he has to eat smaller portions
of food, this will help him feel fuller longer.
1.0 g protein x 75.5 kg body weight = 76 grams per day.
14. Identify at least two pertinent nutrition problems and the corresponding nutrition
diagnoses.
Obese Class III, related to excessive energy intake, as evidenced by current weight at 247% of
ideal body weight.
Physical inactivity, related to sedentary lifestyle, as evidenced by long-term involuntary weight
gain.
15. Determine the appropriate progression of Mr. McKinleys post-bariatric-surgery diet.
Include recommendations for any supplementation you would advise.
For the first six weeks after surgery, Mr. McKinley should exclusively follow a pureed/liquid
diet. Simple sugars should be completely avoided in the early stages. Since patient may initially
be lactose-intolerant, dairy products should also be avoided. After the initial six weeks, he can
transition to small, frequent meals of nutrient-dense foods. Liquids should be consumed at least
3060 minutes after solid foods. Eventually, the pouch will expand to accommodate up to 45
ounces of food/liquid at a time. Mr. McKinley should focus on eating slowly and chewing food
thoroughly. Its important to get adequate protein, both to support wound healing during the
postoperative stage, and to facilitate building muscle mass during the period of weight-loss.
Calorie-dense liquids should be avoided (e.g., milkshakes, sodas, juices) as they may cause
dumping syndrome, with the unpleasant symptoms of abdominal pain and diarrhea.

Mr. McKinleys procedure, Roux-en-Y (aka RYGB), causes both gastric restriction and nutrient
malabsorption; because of the malabsorption, nutritional deficiencies can result. The incidence of
nutritional deficiencies after RYGB is approximately 27%. The RYGB procedure bypasses the
first section of the duodenum which is a site of absorption for numerous minerals and vitamins,
including all the fat-soluble vitamins. As a consequence, supplementation with B12, folate, iron,
calcium, and vitamins A, D, E, and K may be necessary. A liquid multivitamin and mineral
supplement should be initiated preventatively. Some patients will need regular injections of B12.
Mr. McKinleys serum levels of pertinent nutrients should be checked periodically as part of his
ongoing postsurgical follow-up.
16. Describe any pertinent lifestyle changes that you would view as a priority for Mr.
McKinley.
Mr. McKinley will need to carefully follow the recommended postoperative diet for patients who
have undergone RYGB bariatric surgery. He will need to eat small amounts of food throughout
the day. Due to the ongoing potential for nutrient deficiencies inherent in the RYGB surgery, he
will need to maintain a well-balanced diet. Certain social events may present difficulties (e.g.,
brunch buffets, dinner parties, Thanksgiving and Christmas dinners) and hell need to develop
strategies to handle them. Ongoing work with a counselor will be important to maintain his
motivation and confidence.
Exercise and regular physical activity will be crucial to help him lose weight, and to maintain the
weight loss. It will also build muscle that will alter his body composition and raise his
metabolism. Ideally, exercise will contribute to the development of a healthier self-image and a
feeling of body-positivity that will motivate him to continue his new healthful habits.
I would recommend that Mr. McKinley start with walking daily, and as he builds stamina, I
would suggest that he try out many different sports and physical activities to see what he enjoys
the most. Light weight training would be very helpful in building muscle. I would also
recommend that he look into getting a real estate license, and consider a career change from
office manager to real estate agent. He will get much more physical activity throughout the day,
and in addition to the added exercise, he will be meeting more people as well, boosting his social
and physical confidence.
17. How would you assess Mr. McKinleys readiness for a physical activity plan? How does
exercise assist in weight loss after bariatric surgery?
Recovery time varies from person to person after surgery. To assess Mr. McKinleys readiness
for physical activity, I would speak to him about his pain, and what activities may feel
challenging for him after surgery, and ask him what he feels ready to try. I would speak to him
about his energy level, and if he is comfortable starting a very low-impact exercise plan. I would
start him off very slowly with walking, and suggest he increase his pace and time to what feels
most comfortable for him over a span of several weeks. I would recommend he abstain from
heavy lifting and high impact workouts for at least 6 weeks, and at that point we will meet and
assess where he is in the healing process. I would also discourage swimming until his external
wounds have healed.

Exercise after bariatric surgery can help Mr. McKinley increase and maintain his weight loss,
increase his muscle mass and thusly boost his metabolism, as well as help him manage his stress,
control his blood sugar, and strengthen his lungs, heart, and bones.
18. Identify the steps you would take to monitor Mr. McKinleys nutritional status
postoperatively.
The results of Mr. McKinleys procedure should be monitored in order to evaluate the success of
the intervention. This can be accomplished by collecting data in four general categories:
Nutrition-related history data: Mr. McKinley should meet with an RD periodically to discuss
how he feels his health and habits have changed or improved. Types of foods eaten, quantities
eaten, food knowledge, energy level, and sense of well-being can all be evaluated.
Anthropometrics: Body weight, body measurements, BMI, and body composition values can be
assessed and compared with previous values.
Biochemical data: Lab values should be evaluated at regular intervals, particularly for those tests
that had previously been outside of normal parameters, including potassium, glucose, CPK,
cholesterol, HDL-C, VLDL, LDL, triglycerides, and HbA1C. If there are concerns about
nutritional deficiencies, lab tests can be ordered to evaluate whether nutritional intake is adequate
given the inevitable malabsorption issues.
Nutrition-focused physical findings: Physical signs such as ecchymosis, petechiae, edema,
abrasions, skin rashes, blood pressure, and distal pulses can be checked for improvement.
19. From the literature, what is the success rate of bariatric surgery? What patient
characteristics may increase the likelihood of success?
Bariatric surgery is considered to have a high success rate in helping patients achieve lasting
weight loss, and reducing the incidence of comorbidities related to obesity. For weight loss
surgeries in general, the sustained weight loss at 23 years post-op is 2035% of the starting
weight. For the Roux-en-Y procedure specifically, up to 80% of diabetic patients experienced
complete remission of their diabetes; research on the results of the RYGB procedure found that
patient risk of mortality from obesity-related causes (coronary heart disease, diabetes, and
cancer) was reduced by 40%. With regard to dyslipidemia and hypertension, the long-term
improvement rate was 6070%.
Certain patient characteristics increase the likelihood of success, the most important being a
motivation to lose weight and keep it off by making the necessary dietary and lifestyle
adjustments. Patients should be willing to adhere to the postoperative dietary recommendations,
and committed to long-term follow-up. Candidates for bariatric surgery should be free of serious
psychopathologies, and possess the physical and emotional stamina to undergo this life-changing
operation. For long-term success, it is important that the patient have access to individual and/or
group counseling.