Case 2: Bariatric Surgery for Morbid Obesity

Understanding the diagnosis and pathophysiology

1) Understanding the BMI and percent body fat criteria for the classification of obesity.
What BMI is associated with morbid obesity?
- The BMI associated with morbid obesity is over 35 kg/m^2 if there is also an obesity-
related health condition involved. A BMI of 40 or greater is associated with morbid
obesity if there are no other health conditions
- There are many classes with obesity
o Obesity class 1: 30-34.9 kg/m^2 is moderate.
o Obesity class 2: 35-39.9 kg/m^2 is severe with one or more comorbid conditions.
o Extreme obesity class 3: > or equal to 40 kg/m^2

2) List 10 health risks involved with untreated morbid obesity. What health risks does
Mr. McKinley present with?
- Mr. McKinley has hypertension, hyperlipidemia, osteoarthritis, and type 2 DM. His
cholesterol is elevated, and his HDL levels fall under the reference range.
- Other health risks involved with morbid obesity are cancer, breathing problems,
NAFLD, reduced testosterone levels, menstrual abnormalities, asthma, sleep apnea, and
premature death.

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.
- If you want to get bariatric surgery, you must have a BMI of 40 or higher or a BMI of 35
with other problems such as the health risks discussed in question 2. Prior treatment of
diet and lifestyle intervention and pharmaceutical drugs must have failed, plus the
patient must demonstrate that they are motivated to keep the weight off and understand
the strict lifestyle change they must sustain post-surgery and lifelong.
- Mr. McKinley’ has a BMI of 59 and qualifies for the surgery. In the past he has lost up
to 75 pounds which shows his motivation to be healthy. He has had difficulty sustaining
the weight loss. His extreme obesity and chronic diseases put him in a life-threatening
state. Therefore, the bariatric benefits outweigh the negatives.

4) By performing an Internet search or literature review, find one example of bariatric

surgery program. Determine 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
- An example of a bariatric surgery program is demonstrated from Penn Medicine. Their
qualification for surgery included:
o Body weight greater than 100 pounds above ideal body weight
o BMI greater than 40 or 35 with medical complication
o Failed weight loss attempts
o No indication of alcoholism, drug addiction, or psychiatric disorder
- A doctor will then do tests such as abdominal ultrasounds, blood studies, cardiac clearances,
chest x-rays, ECG, CKG, sleep study, and much more. Hospital stay and length of time under
nurse, dietician, and doctor care is determined by the type of surgery. Dietitians will discuss with
the patient the importance of following the strict diet and the doctors will provide the patient
with exercise recommendations (Penn Medicine, 2018).

5) Describe the following surgical procedures used for bariatric surgery, including
advantages, disadvantages, and potential complications.
a. Roux-en-Y gastric bypass:
- This is the most common type of surgery, but also the most malabsorptive. The surgeon
creates a pouch by dividing the upper end of the stomach and restricting food intake. A
part of the s.i is attached to the pouch which allows food to bypass the duodenum and
first part of the jejunum. The small intestine is reconnected to the pouch, so ingested
food and enzymes mix. Advantages include increased weight loss compared to the other
methods, low mortality, and significant long-term weight reduction. Disadvantages
include dumping syndrome and the possibility of hernias.
b. Vertical sleeve gastrectomy:
- This removes a large portion (about 80%) of the stomach, stapling it back together, and
leaving it about the size of a banana. This does not involve cutting sphincter muscles that
allow food to enter and leave the stomach. Advantages include rapid weight loss.
Disadvantages are complications that are rare (like a leak) can occur. There is little long-
term data on this weight loss method.
c. Adjustable gastric banding (Lap-Band):
- This operation restricts and decreases food intake but doesn’t interfere with digestive
processes. A band is placed around the upper end of the stomach, creating a small pouch
and narrow passage to the remaining part of the stomach. This passage delays the
emptying off food, so you feel fuller. Advantages are the surgery requires a shorter
hospital stay (24 hours), and has one of the lowest rates of complications, mortality, and
deficiencies. This procedure is also reversible. Disadvantages include slower weight loss
than other procedures. Complications include the possibility that the band can slip or
erode.
e. Duodenal switch:
- This procedure restricts food intake and food amount. A big portion of the stomach is
left intact including the pyloric valve, and the duodenum is divided as well as the small
intestine. Pros include the great amount of weight loss and low risk of complication.
Cons include a strict diet, food malabsorption, dumping syndrome, and leakage.
f. Biliopancreatic diversion:
- This is less common and involves distal gastrectomy laparoscopically. Advantages
include sustainable weight loss that may be more efficient than RYGM or relative
procedures. Disadvantages include higher complications than other procedures.

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 altogether. 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?
 - Bariatric surgery can change insulin secretion and sensitivity, which can improve
glucose regulation. In the first 6 weeks, insulin sensitivity improves while insulin
secretion increases which results in normal glucose homeostasis. When a patient is
within normal weight range, receptors are better at sensing the ability to control insulin.
- Other medical conditions that can be affected by weight loss are high blood pressure
because within 2 and 3 months’ post operation, blood pressure may possibly return to
normal numbers. His high cholesterol will also likely reduce since more than 80% of
patients will develop normal cholesterol within 2-3 months post- op. Patients who
experience asthma attacks and GERD have also seen improvement. Additionally, there
can be a relief in sleep apnea and snoring from those patients who lose weight.

7) How does the Roux- en- Y procedure affect digestion and absorption? Do other
surgical procedures discussed in question 5 have similar effects?
- The RYGB reduces calorie absorption by reducing the stomach to a small upper pouch.
It is connected by the roux limb to the jejunum which bypasses the duodenum. The
Biliopancreatic limb is what connects the rest of the stomach, and this is where it carries
gastric juice, pancreatic juice, and bile to the jejunum.
- This procedure increases the risk for poor digestion and malabsorption. Food is
transported through the roux limb, which prevents the mixture of food with digestive
enzymes. Less HCl is secreted in the stomach, intrinsic factor is not as active, and
vitamin b12 absorption decreases. Vitamin and mineral absorption is compromised
because the food bypasses the duodenum which is the site of absorption. The other
surgical procedures in question 5 have similar effects.

8) On post-op day one, Mr. McKinley was advanced to the stage 1 bariatric surgery diet.
This consists of sugar-free liquids, broth, and sugar free Jell-O. Why are sugar free foods
used?
- Dumping syndrome is when foods with high osmolarity like sugar move quickly to the
stomach and small intestine which can cause sweating, dizziness and low blood pressure,
which can happen after surgery. This is why sugary foods and foods with high
osmolarity are avoided.

9) 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-ex-Y patient.
How might the nutrition guidelines differ if Mr. McKinley had undergone a lap-band
procedure?
- The major goals of this diet are to make sure that Mr. McKinley is consuming small
meals because of the nature of the Roux-en-Y surgery. This procedure is restrictive-
malabsorption, and the stomach has a new capacity that he is not used to. He should
focus on avoiding foods high in sugar to make sure he does not experience dumping
syndrome, and he should have calorically dense foods high in protein, so his body heals
quickly after the surgery.
- If this patient had a lap-band procedure, he would not have to worry about becoming as
nutrient deficient in comparison to the procedure he went through. The lap band
procedure doesn’t interfere with digestive processes and is generally a safer procedure
with less need to limit certain foods.
10)Mr. McKinley’s RD has discussed the importance of hydration, protein intake, and
intakes of vitamins and minerals, especially calcium and iron and b12. For each of these
nutrients, describe why a deficiency may occur and explain the potential complications that
could result from deficiency.
- Hydration: Consuming liquids in between meals helps with lowering the risk of
dumping syndrome. Liquids can enter into the jejunum quickly and not be able to
tolerate this along with food. Also, diarrhea can occur with this syndrome and water can
be lost through the stool.
- Calcium: It is discouraged after surgery to have high fat foods because of the risk of
dumping syndrome. This includes some dairy products, so not much calcium should be
consumed at this time.
- Iron: Iron is absorbed across the brush border of the intestines. Iron needs acidity of the
stomach, but this is bypassed due to the surgery. Iron may not be absorbed properly and
lead to anemia.
- Vitamin B12: There is a limited amount of HCl in the stomach after surgery because the
upper part of the small intestine is bypassed, and some nutrients and minerals are not
absorbed. Intrinsic factor will be scarce without HCl, which is needed for B12
absorption. This can affect brain function and result in anemia.
- Protein: A patient has a lower capacity to ingest as much food as they used to with the
surgery, and they must restrict food in order to keep the weight off. Protein is also
needed in higher volumes post op due to healing. Protein energy malnutrition can occur
if the patient does not properly eat nutrient dense meals. Protein plays a vital role to
heal wounds, maintain and build muscle mass, make hormones and enzymes, blood
clot, maintain blood pressure, and healthy immune functioning.

Nutrition Assessment

10)Asses 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 goal weight.
- Height: 410 lbs
- Weight: 5’10
- BMI: 59 kg/m^2
- % usual body weight: current body weight/usual body weight x 100
= 410/434 x 100 = 94.4%
IBW: 106 lbs + 10(6) = 166 lbs
- Reasonable weight goal: 337 -312 lbs in 6 months
- Rationale for this method: According to research, it is expected to lose 30-40% of excess
weight within 6 months’ post-surgery. If Mr. McKinley has 244 lbs of excess weight, he should
be able to lose 73- 98 lbs of it in 6 months.

11) After reading the physician’s history and physical, identify any signs or symptoms that
are most likely a consequence of Mr. McKinley’s morbid obesity.
 - Due to Mr. McKinley’s morbid obesity, he is suffering with the consequences of Type 2
DM, HTN, hyperlipidemia, and osteoarthritis, and edema. Through observation, he
appears to have a rash under his abdominal skin folds which is a consequence from extra
abdominal fat. After doing a physical examination and reading through his history, it is
important to mention to recognize his surgical history. Likely as a result of his excessive
weight on his joints, Mr. McKinley had a right total knee replacement.

12) Identify any abnormal biochemical indices and discuss the probable underlying
etiology. How might they change after weight loss?
- High Potassium, glucose, CPK, cholesterol, VLDL,LDL, LDL/HDL, triglycerides,
HbA1c usually decrease with weight loss. Low HDL will also probably increase. The
cause of high potassium may be due to the diet of the patient or side effects of his
prescription drug, Lovastatin. High glucose and HbA1c are caused by his Type 2 DM.
High CPK is probably caused by his HTN and it contributes to higher risk for heart
attack. High cholesterol and the imbalance of HDL to LDL is caused by a multiple of
factors including poor diet high in Trans and saturated fat.

13) Determine Mr. McKinley’s energy and protein requirements to promote weight loss.
Explain the rationale for the method you used to calculate these requirements.
Using Mifflin-St. Jeor:
- 10(W in kg)+6.25(H in cm)-5(age in y)+5
10(186)+6.25(177.8)-5(37)+5
1860+1111-185+5 = 2791 kcal
- times activity factor: 1 = 2791 kcal/day
- minus 500-750 (up to 1000) I subtracted 1000 kcal to make it closer to 1500-1800 kal
range = 1791-2091 kcal/day. Though, he should begin at a higher calorie range and
gradually decrease with 20 percent of calories from protein.
Protein intake (1791 kcal*.2)/4= 89.55 gm protein/day
Protein intake (2091 kcal *.2)/4= 104.55gm protein/day
•25 kcal/kg IBW
IBW: 106 lbs + 10(6) = 166 lbs 166lbs/2.2 = 75.5 kg
25 kcal/75.5 kg = 1886 kcal/day – results are inconsistent with 1500-1800 kcal/ day

14) What are two pertinent nutrition problems found in the standard American diet in the
US?
- In the US, two pertinent nutrition problems are the high sugar and trans-fat found in the
Standard American Diet. The corresponding nutrition diagnoses that can result from
overconsumption are Type 2 DM with H1Abc of over 6 percent and high cholesterol
with LDL levels of 189 mg/dL or higher.

15) Describe the appropriate diet progression of Mr. McKinley’s surgery

 - The appropriate progression of Mr. McKinley’s post-bariatric-surgery diet includes
moving towards stage 1. After UGI study showed negative for leak, he can sip Bariatric
Clear Liquids that are low-kcal, low or no sugar, carbonation, caffeine, or alcohol.
- In stage 2 which is post-op days 2 & 3, he will continue on Bariatric Clear Liquids with
24-32 oz per day. Additionally, he will add Bariatric Full Liquids with 24-32 oz per day
that are under 25 grams sugar & contain 25-30 grams protein per serving. Some
examples include skim, low-fat, lactose-free, or plant- based milk with protein powder,
and smooth yogurts. This stage also requires supplementation with chewable
multivitamin w/minerals twice a day, chewable or liquid calcium citrate with vitamin D
(1200-1500 mg per day) and additional vitamin D 3000 IU per day, and sublingual
vitamin B12 350-500 mcg per day.
- In stage 3 which is post-op days 10 to 14, he will eat 3 to 6 small meals slowly and can
have liquids in between them or at least 30 minutes after. The drink he can consume
include Bariatric Clear Liquids which will increase to 48-64 oz per day. In replacement
of Bariatric Full Liquids, he can eat soft, moist, pureed, ground, or diced proteins such as
yogurt, cheese, eggs, fish, poultry, ground meats, and cooked beans. In the 2nd week in
stage 3, he can add well-cooked, soft vegetables and fruits and consume more proteins if
well-tolerated. In the 3rd week in stage 3, health care staff must ensure adequate
hydration, consumption of 1 to 2 oz. protein 3 to 5 times a day with fruits and
vegetables, and vitamin-mineral supplementation. If tolerated, he can start salads and
reintroduce grains at 4-6 weeks post-op.
- In stage 4 which is 4 weeks post-op, as he tolerates more food, he can eat a healthy,
balanced solid-food diet consisting of adequate protein, vegetables, fruits, and whole
grains to meet estimated needs and use vitamin-mineral supplementation.

16) What lifestyle changes should Mr. McKinley make post-surgery?

- Pertinent lifestyle changes that would be a priority for Mr. McKinley is making sure to
eat small frequent healthy meals and continue to take supplements because the bariatric
surgery alters the GI tract. This alteration affects folate, iron, calcium, and vitamins
A,D,E, K and B12 absorption and requires supplementation. Also, I would recommend a
low-intensity workout routine such as walking for 150 minutes a week for his
osteoarthritis.
17) How should you monitor Mr. McKinley nutritional status post-op?
- To monitor Mr. McKinley’s nutritional status post-op, we would schedule weekly weigh-
ins with an expected weight loss of 1 to 2 lb. per week and also check-in every 3 weeks
with his meal logs.
18) Describe the success rate of bariatric surgery
- The success rate of bariatric surgery is 20-35% of initial weight lost and is more common
in patients who recognizes the need for & benefits of weight loss, wants to lose weight,
has motivators & realistic goals for wt loss, does not have higher than usual stress levels,
is being treated for any mood or eating disorder, understands the requirements of Tx and
believes he or she can fulfill them.
19) What I required for bariatric surgery in children and adolescents?
 - For children and adolescents, first line treatments must be addressed and if comorbidities
are present, they might be able to proceed with bariatric surgery. According to Stanford’s
Children Hospital, the patients must undergo a 4 to 6 month medical and psychological
evaluation. Additionally, they are required to commit to dietary changes and an exercise
plan as part of the program, which takes a multidisciplinary approach that includes
nutrition counseling and meeting with the program’s psychologist and social worker.
20. Write an ADIME not for your inpatient nutrition assessment with initial education for
the Stage 1(liquid) diet for Mr. McKinley.
Assessment:
37-year-old man admitted for Roux-en-Y gastric bypass surgery on 2/24. Height of 5’10” and
weight of 410 lbs, with a BMI of 58.8 kg/m^2. Morbidly obese, UBW of 434 lbs, and has been
obese the majority of his life. He has type 2 diabetes mellitus, hypertension, hyperlipidemia,
osteoarthritis and received a right total knee replacement 3 years ago. Family history of type 2
diabetes mellitus, CAD, hypertension, COPD, and osteoporosis. Takes prescriptions: Metformin
1000 mg/twice daily, 35 u Lantus at night, Lasix 25 mg/day and Lovastatin 60 mg per day. Lives
a sedentary lifestyle, casually drinking 2-3 beers per week. Normal temperature, and pulse with
high respiration rate of 23, and blood pressure of 135/90. Normal physical assessment except for
edema, ecchymosis, petechiae on lower extremities, rash under abdominal skin folds. High
potassium, VLDL, LDL, LDL/HDL ratio, glucose, CPK, cholesterol, triglycerides and HbA1c
%.

Diagnosis:
Excessive Sugar intake related to consumption of refined sugar as evidenced by a H1Abc of 7.2.
Excessive Fat Intake (NI-5.6.2) related to consumption of fatty foods as evidenced by high
cholesterol level of 320 mg/dL and LDL levels of 232 mg/dL.

Intervention:
Postoperatively, he will receive nutrition counseling and education to make sure he knows how
to assume a strict diet with his bariatric surgery. Immediately after surgery for the first three
days, he will proceed to a nutrition phase 1, or clear liquid diet. He will consume 400 calories of
a mixture of the following: sugar free jello, water, clear broth, sugar-free popsicles, crystal light,
sugar free beverages or decaffeinated tea/coffee. Once he is discharged, he will continue on with
phase 2-5, and incorporate walking 5 times a week, 10 minutes each time. He will consume 64
ounces of fluid daily. He will eat a high-protein, low sugar, low fat diet with small frequent
portions.

Monitoring and Evaluation:

Postoperatively, we plan to reassess Mr. McKinley’s lab values daily until he is
discharged from the hospital. After he is discharged, his lab values will be monitored once a
month to ensure all values are within reference range and we will proceed with supplements
tailored. Other than lab assessment, we plan to assess Mr. McKinley’s food intake and physical
activity through a food log. The food log will detail what he ate, when he ate and the amount. In
his counseling appointments, we will discuss log suggestions. During nutrition counseling,
weight will be measured, and BMI will be calculated and diet and exercise plans will be revised.
 References:

Adolescent Bariatric Surgery Program at Lucile Packard Children’s Hospital Stanford Receives
Landmark Accreditation. (2017, February 23). Retrieved from Stanford Children's Health
website: https://www.stanfordchildrens.org/en/about/news/releases/2017/adolescent-
bariatric-surgery-center-receives-landmark-accreditation

Penn Metabolic and Bariatric Surgery. (2018) Penn Medicine. Retrieved from
https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-
service/bariatric-surgery