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Jake Dudley9/02/2014Dr. VanceNTD 3300Questions on Case Study 2: Bariatric Surgery for Morbid ObesityUnderstanding the Diagnosis and PathophysiologyDiscuss 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.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.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.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 greaterA BMI?of 35 or greater with one or more co-morbid conditionOther common guidelines include:Understanding the risks of bariatric surgeryCommitting to dietary and other lifestyle changes as recommended by the surgeonHaving a history of weight loss treatments having failed the patientUndergoing 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.Describe the following surgical procedures used for bariatric surgery, including advantages, disadvantages, and potential complications.Roux-en-Y gastric bypassThis 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 tovertical 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 andinternal hernias.Vertical sleeve gastrectomyVertical 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.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 thestomach. 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.Vertical banded gastroplastyDuring 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.Duodenal switchDuodenal 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.Biliopancreatic diversionBiliopancreatic 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 challengingoperation 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 channelMr. 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: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 cholesterolAsthma, respiratory insufficiency Sleep apneaImprovement in the patients ability to exercise.Gastroesophageal reflux disease (GERD)Gallbladder disease Low back painAny other comobity that can be attributed to high adipose tissue in the body.Understanding the Nutrition TherapyOn 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 whenfood 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.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.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 ? 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 goodhealth. 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. Nutrition AssesmentAssess 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. Sixmonths 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 kg5’10’’ = 70’’1’’ = 0.0254m(70’’)(0.0254m) = 1.778 mBMI= weight (kg) / height (m)^2186.364 kg / 1.778 m2= his BMI=58.95% UBW Calculation:Current body weight= 186.4 kgUsual 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.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.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?190HDL?C (mg/dL) 32Normal >45VLDL (mg/dL) 45Normal 7?32LDL (mg/dL) 232Normal <130 LDL/HDL ratio 7.5Normal <3.55Triglycerides (mg/dL) 245Normal 40?160CPK (U/L) 220Normal 55?170HbA1c (%)7.2Normal 3.9?5.2Potassium (mEq/L) 5.8Normal 3.5?5.5Glucose (mg/dL) 145Normal 70?110Mr. 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.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 AdultsTEE= 1086 – 10.1 x age + PA x (13.7 x weight + 416 x height)Age = 37 years oldPA = 1.00 for sedentary lifestyleWeight= 182.6 lbs = 83 kgHeight = 70in = 1.778mTEE= 1086 – 10.1 x 37 + 1.00 x (13.7 x 83 + 416 x 1.778)TEE= 2589Protein:Estimated calorie range: 2000?2500 kcals/ day2000 x 15% = 300 kcals protein2500 x 15% = 375 kcals protein300 kcals protein x(1 gram protein/ 4 kcals) = 75 grams protein375 kcals protein x(1 gram protein/ 4 kcals) = 94 grams proteinNutrition DiagnosisIdentify 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.Nutrition InterventionDetermine 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 ? 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.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.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 lowimpact 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. Nutrition Monitoring and EvaluationIdentify the steps you would take to monitor Mr. McKinley’s nutritional status postoperatively.1. Reassess lab values2. Food Diary upon realease3. Exercise Diary to recording duration, intensity, type and any information realting to his physical status post-op.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 gastricbypass 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.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. 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. Nutritioneducation 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 programResourcesMedical Nutrition Therapy : A Case Study Approach. 4th EditionNutrition Therapy and Pathophysiology 2nd WHO.int ................
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