FN 418/618: Medical Nutrition Therapy II Spring 2017

MNT Case Study for Bariatric Surgery

Dakota Cossairt

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PES statement: what is his current nutrition problem? not what got him here, you are concerned with what is

Missed the big picture on what his surgery was about and what your role as the RD was. What was the nutri

you will see him again in 1 week

A
Mr. McKinley is a morbidly obese 37 yo white male. Hes been admitted for a
Roux-en-Y gastric bypass surgery. He has weighed over 250# since age 15,
and has continued to gain weight since then. Mr. McKinley reached his
highest weight of 434# 6 months ago, but has now lost 24# since beginning
a preoperative nutrition education program.
Mr. McKinleys medical history consists of type 2 diabetes mellitus,
hyperlipidemia, hypertension, and osteoarthritis.
Medications include Metformin, Lasix, Lovastatin, and Lantus pm.
Family medical history includes father with type 2 DM, CAD, Htn, COPD, and
mother with type 2 DM, CAD, and osteoporosis.
His most recent lab values indicate increased levels of potassium, glucose,
cholesterol, LDL, triglycerides, HbA1c, and decreased levels of HDL-C.
Current fluid requirements are 1800-2000 mL and he has been cleared to
progress to Stage 1 Bariatric surgery diet.

Ht. = 70 Wt. = 410# BMI = 58.8 BP = 135/90

mmHg

Recommended kcals = 20002500 kcals/ day

Recommended protein = 75-90 g/day

D Food and nutrition related knowledge deficit R/T type2 diabetes and
morbid obesity AEB BMI of 58.9, elevated triglyceride and elevated blood
glucose levels.

I RD recommends patient to get 2000-2500 kcals/day. RD will educate

patient on low sodium foods and heart healthy diets. RD will provide patient
with things he can incorporate in his everyday life to increase physical
activity.

ME
Schedule f/u in 1 month. Ask patient to keep food and activity logs. Reassess
lab values.

1-Day Meal Plan

Breakfast
2 large eggs
1 oz cheddar cheese
Chives
1 cup diced tomatoes
cup avocado slices

Snack
1 cup fat-free greek yogurt
1 cup raw veggies of your choice

Lunch
cup non fat refried beans
2 oz. shredded chicken breast w/ taco seasoning
1 cup shredded lettuce
cup diced tomatoes
2 tablespoons salsa
cup guacamole

Snack
1 large apple
1 oz. walnuts

Dinner
4 oz. broiled salmon w/ rosemary and lemon
cup brown rice
1 cup roasted bell peppers
2 tbsp. olive oil
Questions
1. Discuss the classification of morbid obesity.
a. 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?
a. Untreated morbid obesity can often lead to health risks such as
type 2 diabetes, lipid abnormalities, high blood pressure,
different types of cancers, breathing problems, and premature
death.
b. Mr. McKinley has the health risks of type 2 diabetes, high blood
pressure and hyperlipidemia.

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.
a. Should be >100# over ideal weight range
b. BMI >40 or BMI >35 with co-morbidities
c. Have a history of not being able to lose weight
d. The criteria that qualifies Mr. McKinley for surgery are his
diagnosis of DM2 and his BMI of 58.8

5. Describe the following surgical procedures used for bariatric

surgery, including advantages, disadvantages, and potential
complications.
a. Roux-en-Y gastric bypass done by creating a small pouch by
dividing the upper end of the stomach, which restricts the intake
of food. It creates a direct connects from the stomach to the
lower segment of the small intestine. Food then bypasses
portions of the digestive tract that absorbs calories and
nutrients.
i. Advantages
 1. Significant long-term weight loss
2. Restricts amount of food that can be consumed
3. Produces favorable changes in gut hormones that
reduce appetite and enhance satiety
ii. Disadvantages
1. Complex operation that could possibly lead to
greater complication rates
2. Can lead to long term vitamin/mineral deficiencies
3. Have longer hospital stay
iii. Potential complications
1. Leakage through staples or sutures
2. Bowel obstruction
3. Ulcers in stomach or small intestine
4. Blood clots
5. Stretching of pouch or esophagus
b. Vertical sleeve gastrectomy removes a large portion of the
stomach, which leaves the stomach to be about the size of a
banana. Works by limiting the amount of food one can eat by
making the person feel full after eating small portions of food.
i. Advantages
1. Restricts the amount of food the stomach can hold
2. Induces rapid and significant weight loss
3. Requires no foreign objects or re-routing of food
stream
4. Relatively short hospital stay
ii. Disadvantages
1. Non-reversible procedure
2. Potential for long-term vitamin deficiencies
3. High early complication rate
iii. Potential complications
1. Gastritis
2. Heartburn or stomach ulcers
3. Injury during surgery to stomach, intestines, or other
organs
4. Leakage through staples or sutures
c. Adjustable gastric banding (Lap-Band) an inflatable band
is placed around the upper portion of the stomach, which creates
a small stomach pouch above the band.
i. Advantages
1. Reduces amount of food the stomach can hold
2. Induces excess weight loss
3. No cutting of the stomach involved or rerouting of
intestine
4. Reversible and adjustable
ii. Disadvantages
1. Slower and less early weight loss
 2. High percent of failing to lose at least 50% of excess
body weight
3. Uses a foreign device to remain in the body
iii. Potential complications
1. Pouch dilation
2. Band slippage
3. Persistent GERD
4. Band erosion
d. Vertical banded gastroplasty the upper stomach near the
esophagus is staple vertically to create a small pouch along the
inner curve of the stomach. A band is then placed on the outlet
of the pouch, which delays emptying of food from the pouch
causing fullness.
i. Advantages
1. Anatomy is left intact
2. Less chance of malnutrition
3. Reversible procedure
ii. Disadvantages
1. Needs strict patient compliance to diet
iii. Potential complications
1. Staple lines could leak causing serious infection
2. Risk of band breaking or moving
e. Biliopancreatic diversion a small, tubular stomach pouch is
created by removing a portion of the stomach, and then a large
portion of the small intestine is bypassed
i. Advantages
1. Results in greater weight loss than many other
surgeries
2. Allows patient to eventually eat near normal meals
3. Reduces absorption of fat
ii. Disadvantages
1. High complication rates
2. High risk for mortality
3. Longer hospital stays
4. Great potential to cause protein deficiencies and in a
number of vitamin and minerals
iii. Potential complications
1. Leakage which could result in abscesses or peritonitis
2. Hemorrhage
3. Pulmonary embolism
4. Myocardial infraction

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?
a. Bariatric surgery could cause diabetes to go into remission or
achieve normal levels. It is not an ensured cure for diabetes, but
it could be one of the best treatments.
b. Other medical conditions that might be affected by weight loss
include sleep apnea, high blood pressure, heart disease,
gallbladder disease, GERD..etc

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?
a. They are used to help prevent dumping syndrome.

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?
a. Major goals for Stage 2 include>64 oz per day, with 24-32 oz of
that being clear liquids, while getting <1/2 at a time. Also a
chewable MVI, and a chewable CA with vitamin D is taken.
b. Major goals for Stage 3 includes continuing with >64oz of fluids
per day, and as tolerated replace full liquids with soft protein
sources. Get 3-6 meals daily. Increase from cup to cup, and
dont drink with meals.

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.

Wt = 410# = 186.4 kg Ht = 510 = 70 = 1.778m

BMI= weight (kg) / height (m)^2
186.34 kg / 1.778 m2
BMI=58.97 59

% 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%

11. After reading the physicians history and physical,

identify any signs or symptoms that are most likely a
consequence of Mr. McKinleys morbid obesity.
a. Hyperlipidemia
b. Type 2 diabetes
c. Total right knee replacement
d. BMI of 58.8

12. Identify any abnormal biochemical indices and discuss

the probable underlying etiology. How might they change after
weight loss?
a. His lab values indicate increased levels of potassium, glucose,
cholesterol, LDL, triglycerides, HbA1c, and decreased levels of
HDL-C.
b. Looking at these values, he is at high risk for heart disease. Also
his high triglyceride level indicates poorly controlled diabetes.
These may change after weight loss if he sticks with a healthful
diet and continues to lose weight.
13. Determine Mr. McKinleys energy and protein
requirements to promote weight loss. Explain the rationale for
the Method you used to calculate these requirements.

TEE= 1086 10.1 x 37 + 1.00 x (13.7 x 83 + 416 x 1.778)

TEE= 2589

Protein:
Estimated calorie range: 20002500 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

14. Identify at least two pertinent nutrition problems and the

corresponding nutrition diagnosis.
a. Food and nutrition related knowledge deficit R/T type2 diabetes
and morbid obesity AEB BMI of 58.9, elevated triglyceride and
elevated blood glucose levels.
b. Physical inactivity R/T sedentary lifestyle AEB weight of 410#
and BMI of 58.9
15. Determine the appropriate progression of Mr. McKinleys
post-bariatric-surgery diet. Include recommendations for any
supplementation that you would advise.
a. ,

16. Describe any pertinent lifestyle changes that you would

view as a priority for Mr. McKinley.
a. Increase physical activity
b. Eat nutrient dense foods that will help him lose weight and help
control his diabetes and hypertension
c. Monitor alcohol intake

17. How would you assess Mr. McKinleys readiness for a

physical activity plan? How does exercise assist in weight loss
after bariatric surgery?
a. Slowly introduce him to low impact activities.
b. Educate him on things he can incorporate in his everyday life to
increase physical activity
c. Exercise assist in weight loss after bariatric surgery by reducing
risks of premature death, diabetes, high blood pressure,
depression and anxiety.
18. Identify the steps you would take to monitor Mr.
McKinleys nutritional status postoperatively.
a. 24-hr recalls and/or food diaries
b. Exercise log
c. Reassess lab values