Question

Bariatric Surgery Case Study

Mr. McKinley is admitted for a Roux-en-Y gastric bypass surgery. He has suffered from type 2 diabetes mellitus, hyperlipidemia, hypertension, and osteoarthritis. Mr. McKinley has weighed over 250 lbs since age 15 with steady weight gain since that time. He has attempted to lose weight numerous times but the most weight he ever lost was 75 lbs, which he regained over a two-year period. He had recently reached his highest weight of 434 lbs, but since beginning the preoperative nutrition education program he has lost 24 lbs.

Height: 5'10" Weight: 410 lbs

McKinley, Chris, Male, 37 y.o. wt

Allergies: NKA

Pt. Location: RM 703 Admit Date: 2/23

Patient Summary: Patient is a morbidly obese 37-year-old white male who is admitted for Roux-en-Y gastric bypass surgery tomorrow morning. Patient has been obese his entire adult life with highest weight 6 months ago at 434 lbs. He has lost 24 lbs since that time as he has been attending the preoperative nutrition program at our clinic.

History:

Onset of disease: Lifelong obesity

Medical history: Type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis

Surgical history: R total knee replacement 3 years previous

Medications at home: Metformin 1000 mg/twice daily; 35 u Lantus pm; Lasix 25 mg/day; Lovastatin 60 mg/day

Tobacco use: None

Alcohol use: Socially, 2–3 beers per week

Family history: Father: Type 2 DM, CAD, Htn, COPD; Mother: Type 2 DM, CAD, osteoporosis

Demographics:

Marital status: Single

Number of children: 0

Years education: Associate’s degree

Language: English only

Occupation: Office manager for real estate office

Hours of work: 8-5 daily—sometimes on weekend

Household members: Lives with roommate

Ethnicity: Caucasian

Religious affiliation: None stated

Admitting History/Physical:

Chief complaint: “I am here for weight-loss surgery.”

General appearance: Obese white male

Case Questions

1. Discuss the classification of morbid obesity.

2. Describe the primary health risks involved with untreated morbid obesity. What health risks does Mr. McKinley present with?

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.

Understanding the Nutrition Therapy

4. 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?

5. 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?

6. Mr. McKinley’s 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.

III. Nutrition Assessment

7. 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.

8. 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.

9. Identify any abnormal biochemical indices and discuss the probable underlying etiology. How might they change after weight loss?

10. Determine Mr. McKinley’s energy and protein requirements to promote weight loss. Explain the rationale for the method you used to calculate these requirements.

IV. Nutrition Diagnosis

11. Identify at least two pertinent nutrition problems and the corresponding nutrition diagnoses.

V. Nutrition Intervention

12. Determine the appropriate progression of Mr. McKinley’s post-bariatric-surgery diet. Include recommendations for any supplementation that you would advise.

13. Describe any pertinent lifestyle changes that you would view as a priority for Mr. McKinley.

14. How would you assess Mr. McKinley’s readiness for a physical activity plan? How does exercise assist in weight loss after bariatric surgery?

VI. Nutrition Monitoring and Evaluation

15. Identify the steps you would take to monitor Mr. McKinley’s nutritional status postoperatively.

Answer 1

1. The morbid obesity is classified as class III OBESITY and body mass index is more than >40 kg/m2

2. Mr. McKinley has Health risks associated with morbid obesity osteoarthritis, hypertension due to circulating blood volume and cardiac output , type 2 diabetes mellitus due to insulin resistance and hyperinsulinemia, and hyperlipidemia

3. If the client is posted for the bariatric surgery, the client body mass index should be between 35 to 39 with or more co morbidities. The co morbidities may be diabetes mellitus, hypertension, and heart disease if the Body mass index is 40 or more than 40 and with co morbidities or without co morbidities. The patient should be 18 years or older patient, the patient has proven failed obesity treatment, there should no endocrine causes for obesity. Obesity related to conditions that has ability to danger the life of the patients.

Mr. McKinley has hypertension, diabetes mellitus, has obesity since 15 years of age, failed weight reduction treatment techniques

4. Eating sugar foods causes dumping syndrome after bariatric surgery. Monosaccharides are easily digested from the abdomen and causes dumping syndrome. Patient are provided with sugar free and high protein diet

5. The special diet is given to the patient at frequent meals after roux en Y procedure. Frequent meals prevent fullness of abdomen and avoiding vomiting. After surgery, there is a chance of vomiting. In order to prevent vomiting, small and frequent diet is given. After lap band surgery, the high protein and low carbohydrates are given

6. After surgery, there is a chance of cobalamin deficiency, folic acid deficiency, iron deficiency, calcium deficiency, causes megaloblastic anemia, iron deficiency anemia that leads blood loss, hemorrhoids.

7 his height 177. 8 cm is converted from inches

His weight 185.973

Body mass index is calculated from dividing the height with weight that is

             185.973

--------------------- ×10000= 58.82

177.8× 177.8

His body mass index should be below the 25 kg/m2. His weight loss should be one to 2 pounds per week that is weekly 500 -1000 calories should be lost to attain weight reduction. Because he has been suffering from diabetic mellitus, osteoarthritis

8. Diabetes mellitus which results in poly uria, polydipisia, poly phagia as a result of insulin resistance. Osteoarthritis that causes symptoms knee pain, due to overweight. Increased blood pressure as result of increased circulatory volume reduced vascular resistance as a result of body mass. Increased triglycerides as a resulted extra glycogen. There is a chance of shortness of breath

9. Increased triglycerides occur due to morbid obesity and increased blood glucose as a result of the increased body mass. After surgery, there is a decrease in blood glucose and blood cholesterol level in the blood because of loss of body mass

10 patients are asked to consume calories 900 to 1000 calorie and 65 t0 75 g of protein per day. Because consumption of food is less, there should be provision higher amount of protein is essential

11. Nutritional problems such as anemia, wernick encephalopathy, osteoporosis due to deficiency of vitamin and folic and iron deficiency and vitamin c, vitamin D

12. Provision of the iron supplements, elemental calcium, vitamin D, multivitamin supplements after surgery

13. He works as office manager that is he is following sedentary life style. Sedentary life style increases chances of weight become higher

14. after surgery, he is prohibited to do exercise until 12 week after surgery. He can walk after surgery. Walking can be advised for him 20 minutes per day and gradually increased over 6-8 week. After 6-8 months after surgery, h e began show weight loss

15. following steps to be taken to identify his dietary pattern after post opertively. in the first 24 hours after surgery, he should be consume water and sugar free liquid diet.after that he can be provided with high protein liquid diet for 2 weeks and after 2 weeks to 4 week, he can be provided with a pureed diet. he is monitored for any bleeding problems due to iron deficiency, poor wound healing due to deficiencey of calcium. monitor his intake and outputand daily weight monitoring helps to identify nutritional status