CASE STUDY #2

BARIATRIC SURGERY FOR

MORBID OBESITY
MODULE 4 CHECK IN ACTIVITY LESSON 1

NUTRITION CARE PROCESS

GROUP 3

AGUIRRE, DARREN
ROXAS, AIEN BELINDA V.
SORIANO, CASSANDRA
VILLAFLOR, ELIJEAN
BARIATRIC SURGERY FOR MORBID OBESITY
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.

CASE QUESTIONS:
I. Understanding the Diagnosis and Pathophysiology
1. Define the BMI and percent body fat criteria for the classification of obesity.
What BMI is associated with morbid obesity?
>The classification BMI for obesity is a range of 30.0-34.9 kg/m^2 (World
Health Organization) and individuals with a BMI above 40 fall into the
classification of morbid obesity. (University Health Care System). For men, a
percentage of body fat greater than 25% defines obesity, with 21-25% being
borderline. For women, over 33% define obesity, with 31-33% being borderline
(Hamdy, 2021, medscape.com) and it can be related to an increased risk of
obesity and metabolic health issues (Nelms, 2016) & (Krause, 2012).
2. List 10 health risks involved with untreated morbid obesity. What health
risks does Mr. McKinley present with?
>Some health risks involved with untreated morbid obesity are premature
death, heart disease, diabetes, cancer, breathing problems, arthritis, reproductive
complications, increased risk of gallbladder disease, high blood pressure, and
depression or emotional mental health consequences (UPMC Life Changing
Medicine). Mr. McKinley has type 2 diabetes which suffers from high blood
pressure/ hypertension, hyperlipidemia and osteoarthritis.
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.
>Bariatric surgery is only allowed for patients with a BMI of 40 kg/m^2
and higher or an individual with a BMI of 35 kg/m^2 and higher if they have
obesity related comorbid conditions associated with their health. Individuals must
 be motivated to lose weight and have had ineffective success with behavioral
treatment with or without the use of pharmacotherapy. The overall factors
contributing to surgery should be based on multiple factors such as patient
motivation, treatment adherence, operative risk and optimization of comorbid
conditions. Mr. McKinley case has currently been having a BMI of 58.8 kg/m^2
classifying him as a morbidly obese individual, thus allowing him to qualify for
bariatric surgery.
4. 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 Yale New Haven Health Hospital bariatric surgery program offers a
comprehensive care for morbidly obese patients during all stages of weight loss.
They perform pre-operative treatment to post-surgery strategies in order to
maintain the health of the patient. All patients must meet certain qualifications in
order to have the surgery performed. The qualifications needed for this bariatric
surgery program are based on BMI, with a morbid obesity of 40 kg/m2 or a 35
kg/m2 with certain health problems associated such as diabetes, hypertension or
obstructive sleep apnea.

>The Yale New Haven Hospital offers three surgery options such as the
Roux-en Y, Lap-Band and the Laparoscopic sleeve gastrectomy approaches.
The team of surgeons bases the final choice of procedure on medical history,
age, BMI and previous weight-loss treatment results. After surgery the length of
the hospital stay can range from 1-10 days depending on the procedure
performed on the patient. For success after surgery the doctors provide the
patient with strict dietary guidelines and exercise recommendations
(https://www.ynhh.org/services/bariatric-surgery.aspx).
5. Describe the following surgical procedures used for bariatric surgery,
including advantages, disadvantages, and potential complications.
a. Roux-en-Y gastric bypass
>During this surgery the entire stomach is removed and usually
reconstructed following. By reducing the size of the stomach with the
stapling procedure at first, then connecting a small opening in the upper
 portion of the stomach to the small intestine with an intestinal loop. This
procedure is restrictive and causes malabsorption because it can prevent
food from being absorbed in the GI tract. The amount of food that can be
eaten at one time is reduced and early satiety is very common.
● Advantages:
-Weight loss is achieved through decreasing absorption, food
intake and increasing satiety
-If patient previously had diabetes an improvement in this disease
can occur after the surgery
-Overall improvement with sleep apnea, hypertension, risk of
cancer and cardiovascular disease
● Disadvantages:
-Possibility of vitamin and mineral deficiency
-Due to the restrictive- malabsorptive procedure there can be
nutrient deficiencies for vitamins A, D, E and K, vitamin B12,
folate, iron and calcium
-Some patients may experience dumping syndrome, tachycardia,
sweating and abdominal pain
● Complications:
-Nausea/ vomiting if too much food is consumed
-Dumping syndrome
b. Vertical sleeve gastrectomy
>During this surgery the surgeon can place rows of staples
through the walls of the stomach and then cut the two sections to
separate them. Up to 85% of the stomach is removed, but the pylorus
remains intact and the stomach function is preserved.
● Advantages:
-Minimal nutrient malabsorption
-By leaving the pylorus intact it reduces the possibility of the

patient developing dumping syndrome.

● Disadvantages:
-This procedure relies more on the decrease of food intake prior to
surgery, so there is a possibility of weight regain.
 -Most complicated procedure
-Only performed on patients with the highest surgical needs due to
high BMI value.
● Complications:
-Infection associated with surgery
c. Adjustable gastric banding (Lap-Band)
>In this procedure a silicone band is placed into the abdominal
cavity around the upper half of the stomach. The band created reduces
the stomach pouch and can be adjusted so that the opening to the rest of
the stomach so it can be made smaller or larger. The band is filled with
saline and has a tube exiting from the surface of the stomach just below
the skin. Additional fluids can be added or reduced into the band.
● Advantages:
-Band can be adjusted for each individual patients needs
-Least invasive procedure
● Disadvantages:
-Patients can lose weight at a slower rate in comparison to other

surgery procedures.
● Complications:
-If the band falls of/ slips prior to surgery another procedure would
need to be performed to adjust it
-Infection associated with surgery
d. Vertical banded gastroplasty
>Gastroplasty reduces the size of the stomach by applying rows of
stainless-steel staples to the partition in the stomach and creates a small
gastric pouch, which leaves a small opening into the distal stomach.
● Advantages:
-Most common gastroplasty
-The total oral intake of a patient is reduced due to the decreased
size of the patient’s stomach, which aids in the weight loss
● Disadvantages:
-This procedure relies on a decrease in food intake prior to the
surgery, so there is a possibility of weight regain
 -If patient consumes too much food, it can cause nausea or
vomiting due to the smaller size stomach
● Complications:
-Breaking of staples
-Infection associated with surgery
e. Duodenal switch
>The duodenal switch procedure is the most complicated of all
bariatric surgeries and is also the least frequently performed. This
procedure consists of a laparoscopic procedure where a vertical sleeve
gastrectomy is performed where a portion of the stomach is removed.
● Advantages:
-Significant weight reduction
● Disadvantages:
-Higher risk surgery and most aggressive procedure
● Complications:
-Surgical complications due to the high BMI needed of patient
-Vitamin and mineral deficiencies
f. Biliopancreatic diversion
>This procedure is often performed with a duodenal switch and is
a restrictive-malabsorptive procedure. It involves the rerouting of food
from the stomach past most of the small intestine in order to further
increase overall weight loss. Other secretions in the liver, gallbladder and
pancreas are rerouted during this procedure
● Advantages:
-Greatest amount of weight loss
● Disadvantages:
-Performed on patients with a BMI of 50 kg/m2 or higher
-Nutrient deficiencies and protein malnutrition
● Complications:
-Vitamin and mineral deficiencies
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?
>The proposed effect of bariatric surgery on the pathophysiology of type 2
diabetes results in a complete cessation of diabetes in up to 80% of patients.
Bariatric surgery in patients with type 2 diabetes not only affects weight loss, but
improves the glycemic levels in patients as well. Along with the change in
glycemic levels, insulin resistance is also reduced. Now that the individual is
within a normal weight range the receptors are more sensitive and the ability to
control insulin has changed. Other medical conditions that might be affected by
the weight loss can include cardiovascular issues, sleep apnea that most obese
patients previously struggle with, hyperlipidemia can improve due to the new
changes in dietary habits and decreased capacity allowed in some procedures
and lastly blood pressure/ hypertension can be lowered with weight loss.

II. Understanding the Nutrition Therapy

7. How does the Roux-en-Y procedure affect digestion and absorption? Do

other surgical procedures discussed in question #5 have similar effects?

>Food travels past the stomach and into the small intestine, where the
majority of the nutrients and calories are absorbed in normal digestion.
The residual waste is finally expelled when it travels through the large
intestine (colon). One type of bariatric surgery is Roux-en-Y gastric
bypass (RYGYB), where a small functional pouch at the top of the
stomach is isolated and connected directly to the jejunum, allowing the
food to bypass the duodenum and most of the stoma This causes the
patient to feel full sooner and decreases appetite. This procedure
interferes with food digestion and nutrient absorption by bypassing part of
the stomach and/ or the small intestine. There is also sleeve gastrectomy,
in which approximately 80% of the stomach is removed, leaving a smaller
sleeve like stomach; and gastric banding, in which an obstructive band is
clamped around the proximal stomach, acting as the restrictive force and
controlling the rate at which food can pass through the stomach. Roux-
en-Y gastric bypass has both restrictive and malabsorptive properties,
 while sleeve gastrectomy and gastric banding are primarily restrictive
procedures.

8. 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 in this stage of Mr. McKinley’s diet to prevent
the possibility of him developing dumping syndrome, which is very
common following bariatric surgery. After gastric surgery, it can be more
difficult to regulate movement of food, which dumps too quickly into the
small intestine. Eating certain foods makes dumping syndrome more
likely. Refined carbohydrates, for example, readily absorb water from the
body, creating dumping syndrome symptoms. Symptoms can also occur
after consuming dairy products, as well as certain fats or fried meals.
Dumping syndrome is common after any gastric bypass surgery. It's a set
of symptoms that can occur after having a portion of the stomach
removed or other stomach surgery. Symptoms might range from
moderate to severe, and they usually go away with time. Although
dumping syndrome might be frightening at first, it is not life threatening.
Changes in what and how one eats will help regulate it. Controlling
dumping syndrome will also help avoid meals that cause weight gain. To
help avoid this, one cannot eat sugar and other sweets such as: candy,
sweet drinks, cakes, cookies, pastries, and sweetened breads/jellies.
Foods to eat are:

● Fiber supplements, such as psyllium (Metamucil or Konsyl),

methylcellulose (Citrucel), or guar gum (Benefiber).
● Sugar replacements, such as Splenda, Equal, or Sweet'N Low,
instead of sugar.
● Complex carbohydrates, such as vegetables and whole-wheat
bread, instead of simple carbohydrates, such as sweet rolls and
ice cream.
 ● To prevent dehydration, drink more than 4 cups of water or other
sugar-free, decaffeinated, noncarbonated beverages throughout
the day.

9. Over the next two months, Mr. McKinley will progress 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?

>People suffering from sleeve gastrectomy and gastric bypass surgery —

also known as Roux-en-Y gastric bypass — would use a gastric bypass
diet to recuperate and modify their eating habits. A doctor or a trained
dietician will discuss the post-surgery diet with the patient, detailing what
foods they may consume and how much they can eat at each meal.
Following the gastric bypass diet to the code will assist the patient in
losing weight safely. The diet is designed to:

● Allow the stomach to heal properly, without it being stretched by

the food that is eaten.
● Get the patient used to eating smaller amounts of food that the
surgically-altered stomach can comfortably and safely digest.
● Aid the patient in weight loss and to help them avoid gaining that
weight back.
● Help avoid the side effects and complications that might arise
from the surgery.

>After surgery, it's important to get adequate nourishment while keeping

your weight-loss goals on track. The physician is likely to recommend that
the patient must:

● Eat and drink slowly. To avoid dumping syndrome, take at least

30 minutes to eat meals and 30 to 60 minutes to drink 1 cup of
liquid. Wait 30 minutes before or after each meal to drink liquids.
 ● Keep meals small. Eat several small meals a day. The patient
might start with six small meals a day, then move to four meals
and finally, when following a regular diet, three meals a day. Each
meal should include about a half-cup to 1 cup of food.
● Drink liquids between meals. To avoid dehydration, The patient
will need to drink at least 8 cups (1.9 liters) of fluids a day. But
drinking too much liquid at or around mealtime can leave the
patient feeling overly full and prevent you from eating enough
nutrient-rich food.
● Chew food thoroughly. The new opening that leads from the
stomach into the small intestine is very narrow and can be
blocked by larger pieces of food. Blockages prevent food from
leaving the stomach and can cause vomiting, nausea and
abdominal pain. Take small bites of food and chew them to a
pureed consistency before swallowing.
● Focus on high-protein foods. Eat these foods before eating
other foods in the meal.
● Avoid foods that are high in fat and sugar. These foods travel
quickly through the digestive system and cause dumping
syndrome.
● Take recommended vitamin and mineral supplements. After
surgery your body won't be able to absorb enough nutrients from
the food. The patient will likely need to take a multivitamin
supplement every day for the rest of their life.

DIET RECOMMENDATIONS FOR LAP-BAND PROCEDURE

PATIENTS

>Adjustable gastric band surgery reduces the size of the opening to your
stomach, which lowers the amount of food the patient can eat. Once they
have received this procedure, they will likely lose a lot of weight, provided
that they follow the instructions. After getting a LAP-BAND, they will need
to follow an entirely new way of eating than they did before the procedure.
It will be about four weeks after the surgery before the patient can eat
solid foods. After the weeks of eating liquid and then pureed foods, the
patient should be able to begin phasing in solid foods.

Limit Carbs Such as Rice, Bread, and Pasta

>Each of these foods expands when it meets gastric fluids. This can lead
to discomfort for some people. It can be helpful to avoid these foods or
eat them only in very limited quantities. Because LAP-BAND surgery
decreases the size of the stomach, it is important to eat small portion
sizes to minimize potential discomfort. Most people tend to eat a quarter
to a half a cup of food at each sitting, for example.

Eat Softened Vegetables and Fruits

>At first, the patient will need to puree any soft fruits and vegetables. If
desired, they may use seasonings, herbs, and spices if they can tolerate
them. Later on, the patient can bring whole fruits and vegetables back
into their diet. The patient must take extra care to avoid fruit skins and
stringy vegetables.

Avoid Eating and Drinking at the Same Time

>This is one of the most important rules to follow after the procedure. The
patient will need to stay hydrated but avoid drinking for 10 minutes before
eating and 45 minutes afterward. In the first few weeks after surgery, the
stomach will be so small that eating liquid and solid at the same time
could lead to vomiting. Water could cause food to be forced out of the
stomach, leading to a feeling of emptiness, which could lead to overeating
as well.

Protein Intake

>Since the surgery will restrict the patient from consuming protein-rich
foods such as meat and eggs, the patient has to consume soft or pureed
protein-rich foods and be careful to get enough of them in your diet. If
necessary, the patient can add a protein supplement as well.

>After surgery, it is possible that the patient will have difficulty with certain
foods. This is known as food intolerance. Experts recommend that people
who have LAP-BAND surgery avoid foods that are very high in fiber, like
celery, corn, oranges, asparagus, pineapples, and sweet potatoes. These
foods may get caught above the band, leaving the patient with a
disagreeable sensation that takes some time to dissipate. Some foods
that commonly trigger intolerance include:

● Salad Greens – Healthy, but high in fiber and may have difficulty
passing through the band.
● Fresh Fruits & Vegetables – High in fiber, with thick skins which
may cause difficulty in digestion.
● Bread – Some types of bread can block the opening of the band,
even after adequate chewing.
● Meat & Dairy – These are a common food intolerance with LAP-
BAND patients.

>Other foods known to cause issues among LAP-BAND patients are:

dried fruit, popcorn, fried foods, and pasta. Food intolerance can make it
difficult to consume enough nutrients with a LAP-BAND, making it very
important to pay attention to the nutritional values of what they eat. For
any gastric bypass patient, it is important to eat well to ensure that the
patient consumes enough nutrients and has a balanced diet. It is also
important to take daily nutritional supplements, as recommended by a
healthcare provider. Missing some vitamins, like Thiamine, can lead to
serious neurological issues if left untreated. If the patient eats healthy and
balanced diet rich in nutrients while avoiding potentially problematic
foods, they could be well on their way to substantial weight loss and a
healthier future.
10. 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 a deficiency may occur and
explain the potential complications that could result from deficiency.

>Bariatric surgery patients are commonly at risk for deficiencies of water-

soluble vitamins B12, B1, folate and C; fat-soluble vitamins A, D, E and K;
and the minerals iron, zinc, selenium, calcium, magnesium and copper.
After bariatric surgery, patients may have trouble with absorption of iron,
vitamin D and calcium, leading to loss of bone density that can continue
for years. Micronutrient depletion is particularly common following
operations that alter digestion and absorption, such as the Roux-en-Y
gastric by-pass (RYGB), the most popular type of weight-loss surgery.
Vitamin B12 insufficiency is substantially increased by RYGB. However,
other B vitamins, particularly B1, as well as minerals, could be impacted.
The second most common surgery, biliopancreatic surgery (BPD),
increases the risk of nutrient deficiencies. Because fat malabsorption is
produced by this technique, the risk of fat-soluble vitamins A, D, and K
appears to be increased. Deficits of thiamine (B1), folate and others
have been reported – especially in “banding” patients experiencing
vomiting, inadequate food intake or rapid weight loss.

Signs and Symptoms

Folate Deficiency Effects

>Folic acid deficiency is a potential complication of bariatric procedures

that can contribute to anemia. The prevalence of this deficit after both
restrictive and malabsorptive procedures ranges from 9% to 39% [23,24].
It can manifest as macrocytic anemia, patrimonial, leucopenia, or
glossitis.

Iron Deficiency Effects

>Most of the iron from foods is absorbed in the first part of the duodenum,
but after a gastric bypass procedure, food bypasses the duodenum. This
can lead to an iron deficiency resulting in nutrition-related anemia,
weakness, and hair-loss.

Calcium and Vitamin D Deficiency Effects

>Vitamin D deficiency is a well-known comorbidity of obesity that can be

exacerbated after bariatric surgery and can predispose the patient for
hypocalcemia; a condition in which there are lower-than-average levels of
calcium in the liquid part of the blood, or the plasma. These deficiencies
can lead to various complications such as osteoporosis, anemia,
neurologic problems, fatigue and generalized weakness. In particular,
changes in calcium and vitamin D handling following bariatric surgery can
induce bone loss, eventually resulting in higher fracture risk.

Vitamin B1 and A Deficiency Effects

>Deficiencies of vitamins B1 and A will sometimes include ocular signs.

One early symptom of low vitamin B1 levels is fatigue since this vitamin is
required for the energy-yielding metabolism of carbohydrates. Overt
deficiency can lead to dry beriberi and even Wernicke encephalopathy
which directly impacts the nervous system. Patients with "bariatric
beriberi" may experience weakness, lightheadedness, blurred vision,
peripheral neuropathies (which often start with tingling in the toes and
hands) and trouble walking.

Protein

>Due to the stomach’s lowered capacity the patient has to restrict the
consumption of food to smaller meal amounts at first, thus they might not
meet all the daily needed requirements for protein. Protein is needed to
help healing post-surgery, so it’s important to consume as much of it as
possible within the limited amounts the patient can consume. Protein
 energy malnutrition can occur if the patient doesn’t consume the needed
amounts.

* For individuals who follow bariatric surgery, lifetime nutritional

assistance is a critical determinant in positive results. After surgery,
patients are at higher risk for micronutrient deficiencies, which can result
in anemia or osteoporosis, among other problems. According to experts,
many patients face dietary problems even before surgery.

III. Nutrition Assessment

11. 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 goal weight.

TANNHAUSER’S METHOD:
IBW = 5’10”
= (5 ft. x 12 in.) + 10 in.
= 70 in. x 2.54 cm.
= 177.8 cm
= 177.8 cm - 100
IBW = 77.8 kg.
Adjust for stature:
IBW = 77.8 kg - (10%)
= 77.8 kg - 7.78 kg
= 70.02 kg or 70 kg

Ht. (m^2) = 3.16

UBW = 434 lbs.
Current Wt. = 410 lbs. / 2.2 kg
= 186 kg
% UBW = current body weight/usual body weight x 100
= 410 lbs. / 434 lbs. X 100 = 94.4 %
BMI = wt. (kg) / ht. (m^2) = 186 / 3.16 = 58.97 ~ 59
BMI = 59 kg/m^2
 >Mr. McKinley currently weights 410 lbs. and has a height of 5’10, which
makes him have a BMI of 59 kg/m2 classifying him as extremely obese.
His usual body weight percentage is 94.4%

* The goal of the client is to lose 2-3 pounds per week. After one (1)
month, the patient’s ideal weight should approximately be 402 lbs.; and, after six
(6) months, 362 lbs. A gradual decrease in weight is ideal so as to not put the
patient into shock or fatigue. Gradual weight loss is also more sustainable than
immediate weight loss.

12. 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.

>Some conditions that are present in the patient’s history and physical reports
are multiple signs and symptoms that are most likely consequences of his morbid
obesity. He has a medical history of type 2 diabetes, hypertension,
hyperlipidemia and osteoarthritis. All of those medical conditions are most likely
related to his morbid obesity.

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

>Some of the abnormal biochemical lab levels present in Mr. McKinley’s test are
levels of potassium, glucose, CPK, cholesterol, HDL, VLDL, LDL, HDL/LDL ratio
and HbA1c. Most of these abnormal levels are attributable to his obesity; type 2
diabetes, hypertension, hyperlipidemia, sedentary lifestyle, medications and
dietary choices. After the weight loss it can be assumed that most of these levels
will return to normal with the proper implication of weight loss and lifestyle
change. After his surgery Mr. McKinley will have to properly adjust and change
his lifestyle in order to maintain his new weight. With proper nutrition, addition of
exercise and monitoring of his post-surgery needs these levels can go back to
normal levels.
14. Determine Mr. McKinley’s energy and protein requirements to promote
weight loss. Explain the rationale for the method you used to calculate
these requirements.
● Energy:
Mifflin-St Jeor Equation:
= (9.99 x W) + (6.25 x H) - (4.92 x A) + 5
= (9.99 x 186 kg) + (6.25 x 177.8 cm) - (4.92 x 37 years) + 5 x 1.2
= 1858.14 + 1111.25 - 182.04 + 5 x 1.2
= 2793.35
= 2750 kcal/ per day
*He should consume 2750-2800 kcals/ per day regularly
* To calculate Mr. McKinley’s energy requirement, the Mifflin St
Jeor equation along with an injury factor of 1.2, which is typically used for
surgery patients, was used.
● Protein:
= 2750 kcal x 0.15
= 413
= 413 / 4 kcal/g
= 103.25 or 103
= 103 g
= 105 g (rounded up from 103 g)
Method for estimating total protein needs: 0.2 or 3.0 protein/kg of
adjusted body.
*After the operation, protein intake must be increased to promote
healing. Normally the recommendation is between 67 to 73 grams
of protein per day. To calculate exact need it is normally 1.0 to 1.5
grams per kilogram of ideal body weight. IBW = 50 kg + 2.3 kg
(inch over 5ft.) = 50 + 2.3 (10) = 73 kg. Therefore, Mr. McKinley’s
protein requirement is between 73 and 109.5 grams per day.
IV. Nutrition Diagnosis
15. Identify at least two pertinent nutrition problems and the corresponding
nutrition diagnoses.

V. Nutrition Intervention
16. Determine the appropriate progression of Mr. McKinley’s post-bariatric-
surgery diet. Include recommendations for any supplementation that
should be prescribed.

DIET RECOMMENDATIONS FOR ROUX-EN-Y PATIENTS

Liquids

Diet recommendations after gastric bypass surgery vary depending on

the individual’s situation. How quickly the patient moves from one step to
the next depends on how fast their body heals and adjusts to the change
in eating patterns. The patient can usually start eating regular foods about
three months after surgery. For the first day or so after surgery, the
patient will only be allowed to drink clear liquids. Once the patient is fine
with handling clear liquids, they can start having other liquids, such as:

● Broth
● Unsweetened juice
● Decaffeinated tea or coffee
● Milk (skim or 1 percent)
● Sugar-free gelatin or popsicles

Pureed foods

After about a week of tolerating liquids, the patient can begin to eat
strained and pureed (mashed up) foods. The foods should have the
consistency of a smooth paste or a thick liquid, without any solid pieces of
food in the mixture. The patient can eat three to six small meals a day.
Each meal should consist of 4 to 6 tablespoons of food. Eat slowly —
about 30 minutes for each meal. There are foods that will puree well,
such as:

● Lean ground meat, poultry or fish

● Cottage cheese
● Soft scrambled eggs
● Cooked cereal
● Soft fruits and cooked vegetables
● Strained cream soups

Blend solid foods with a liquid, such as:

● Water
● Skim milk
● Juice with no sugar added
 ● Broth

Soft foods

After a few weeks of pureed foods, and with the doctor's approval, the
patient can add soft foods to their diet. They should be small, tender and
easily chewed pieces of food.
The patient can eat three (3) to five (5) small meals a day. Each meal
should consist of one-third to one-half cup of food. Each bite must be
chewed until the food is pureed and consistent before swallowing.

Soft foods include:

● Ground lean meat or poultry

● Flaked fish
● Eggs
● Cottage cheese
● Cooked or dried cereal
● Rice
● Canned or soft fresh fruit, without seeds or skin
● Cooked vegetables, without skin.

Solid foods

After about eight (8) weeks on the gastric bypass diet, the patient can
gradually return to eating firmer foods. They should start with eating three
meals a day, with each meal consisting of 1 to 1-1/2 cups of food. It's
important to stop eating before you feel completely full. Depending on
how the patient tolerates solid food, they may be able to vary the number
of meals and amount of food at each meal. A consultation with their
dietitian might be the best course-of-action. Certain foods may cause
pain, nausea or vomiting after gastric bypass surgery.

Foods that can cause problems at this stage include:

 ● Breads
● Carbonated drinks
● Raw vegetables
● Cooked fibrous vegetables, such as celery, broccoli, corn or
cabbage
● Tough meats or meats with gristle
● Red meat
● Fried foods
● Highly seasoned or spicy foods
● Nuts and seeds
● Popcorn

* In addition, doctors recommend that gastric bypass surgery patients

take a complete multivitamin, calcium with Vitamin D, iron and Vitamin C,
Vitamin D, and Vitamin B12. Some deficiencies, such as vitamin B1, can
occur rapidly, while deficiencies of fat-soluble vitamins can take much
longer to develop. Many patients also require extra supplements of
specific nutrients in addition to a daily multi-vitamin and mineral. For
example, current recommendations for gastric by-pass patients include:
10,000 IU vitamin A, 50-100 mg B1, 300-500 mcg of B12 (some may also
require B12 injections), 300 mcg daily of vitamin K, 800-1200 IU vitamin
D and 1200-1800 mg of calcium.

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

To get the maximum benefit after a bariatric surgery, one must make and
continue to choose significant lifestyle changes once the surgery is
complete. These changes will involve altering physical activity, eating
habits, and behavior.

Physical Activity
After recovering from your weight loss surgery, the patient should adopt a
regular exercise program to build muscle mass and burn calories. Once
the physician has cleared the patient for regular physical exertion, they
can try a variety of activities, including but not limited to:

● Weight training
● Swimming
● Walking
● Jogging

Eating Habits

For nutrition and diet intake after bariatric surgery, the types of post-
surgical changes one makes will depend on the type of weight loss
surgery. However, in most cases, the patient will need to go on a
temporary liquid diet then slowly transition to solid foods. Permanent
changes pertaining to diet must be applied, including but not limited to:

● Less sugar and soda intake

● More whole foods
● Smaller portions
● Less frequent snacks.

Behavioral Changes

For the best results, life after bariatric surgery should include as many of
these changes as possible. Certain behavioral changes must also be
applied on a daily basis. Recommended behavioral changes include:

● Drinking a greater amount of water each day

● Cooking nutritious meals at home instead of eating out (lessens
pressure of eating more than what is necessary/consuming
undesirable food choices).
● Taking the stairs instead of the escalator or elevator.
 ● Walking or biking from one place to as much as possible instead
of driving.

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

Physical activity will greatly aid in the patient’s recovery after weight loss
surgery. It will improve circulation, prevent blood clots, help with wound
healing, and assist in bowel function. The patient can begin walking within
the first week. At first, they can attempt to go for many short walks each
day. In two to four weeks after laparoscopic surgery, they should be able
to resume most of their normal activities. If the patient underwent open
surgery, it might take up to twelve weeks. Walking on a regular basis is
recommended to enhance physical exercise. Aerobic exercises like fast
walking and riding can be done right after weight loss surgery. However,
the level of discomfort caused by these activities will be a limiting factor.

Low-impact workouts such as swimming, cycling, and walking are the

finest sorts of activities to pick from. After bariatric surgery, yoga, dance,
running, aerobics programs, and low weights are also popular. It is
advised that the patient consults with their bariatric surgeon and a fitness
specialist to create a program that suits their specific needs, such as
personal preferences, abilities, and weight reduction and active lifestyle
objectives. The patient will most likely be given an exercise regimen that
begins with modest to moderate quantities of physical activity, such as 10
minutes per day, before progressively increasing the quantity. When the
patient is ready, they could incorporate a range of activities that improve
endurance, flexibility, and strength into their regimen. Combining aerobic
workouts with weight resistance exercises will help Mr. McKinley lose
weight and build and strengthen his muscles.

Adults should strive to be physically active on a daily basis. Over the

course of a week, you should engage in at least 150 minutes (212 hours)
of moderate intensity exercise in 10-minute increments. Doing 30 minutes
 at least 5 days a week is one method to go about it. Alternatively, 75
minutes of strong intensity activity spread out across the week or a
combination of moderate and vigorous intensity activity can provide
equivalent benefits. A healthy lifestyle incorporating an exercise
programmed will offer many benefits for a bariatric patient including:

• Maintains weight loss

• Boosts the metabolism
• Reducing the risk of developing heart disease and some types of cancer
• Helping develop and maintain muscle strength, endurance and tone
• Promoting joint stability, bone strength and integrity
• Aiding your ability to perform daily living activities
• Improving skin elasticity
• Elevates the mood, reducing stress and anxiety
• Improves overall health, well-being and mental outlook

VI. Nutrition Monitoring and Evaluation

19. Identify the steps you would take to monitor Mr. McKinley’s nutritional
status postoperatively.
>Some steps that I would take to monitor Mr. McKinley’s nutritional status
postoperatively is to take a 24-hour food recall or food diary, to make sure that he
is consuming the proper amounts and types of food that suit his body post-
surgery. I would also want to see his sugar intake in order to help avoid any
possibilities of having dumping syndrome. I would like to assess if Mr. McKinley
is being compliant with the suggestions of small meal consumption and drinking
liquids between meals as well. I would want to assess his vitamin and mineral
levels in order to see if any deficiency is present. Monitoring his diabetes, weight
loss per week and lipid protein levels would be done through biochemical tests in
order to see if there is any change in his laboratory levels.

20. From the literature, what is the success rate of bariatric surgery? What
patient characteristics may increase the likelihood for success?
>The success rate of bariatric surgery is a mean 20-35% of initial weight
in the following 2-3 years post-surgery. Up to 80% of patients who previously had
 diabetes also experience a complete cessation. Patients who have a RYGB
performed also have a 40% reduction rate of mortality from previous risks such
as coronary heart disease, diabetes and cancer. Patients who have an increased
risk for success maintain their weight loss by eating a relatively low-fat diet of
24% of daily kcals, they eat breakfast almost every day, they weigh themselves
regularly in order to monitor personal success and they engage in high levels of
physical activity that range from 60-90 minutes a day (Nelms, 2016) & (Krause,
2012).
21. 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?
>Children with a BMI in the 85 th percentile or higher with complications of
obesity or with a BMI in the 95th percentile or higher without complications can be
carefully assessed for genetic, endocrinologic and psychological conditions. They
may also be assessed for complications such as hypertension, dyslipidemia,
sleep apnea and any orthopedic problems. After assessment if the complications
cause serious morbidity and require rapid weight loss, they can be referred to a
pediatric obesity specialist. Otherwise, children should try to make a lifestyle
change in regards to physical activity and dietary choices in order to increase
weight loss.
22. Write an ADIME note for your inpatient nutrition assessment with initial
education for the Stage 1 and 2 (liquid) diet for Mr. McKinley.
● ASSESSMENT:
> Anthropometrics:
-410 lbs. and BMI of 59 kg/m2, previous weight of 434 lbs.
-5’10
-37-year-old, male
>Biochemical:
-Increased potassium level of 5.8 mEq/L
-Increased glucose level of 145 mg/ dL
-Increased CPK level of 220 U/L
-Increased cholesterol level of 320 mg/dL
-Decreased HDL level of 32 mg/dL
-Increased VDLD level of 45 mg/dL
 -Increased LDL level of 232 mg/dL
-Increased HDL/LDL ratio 7.5
-Increased triglycerides level of 245 mg/dL
-Increased HbA1c level of 7.2%
>Clinical:
-Patient is diagnosed with hypertension, type 2 diabetes,
hyperlipidemia and osteoarthritis
>Dietary:
-N/A
● DIAGNOSIS:
-Obesity related to excessive energy intake as evidence by a BMI
of 58.8 kg/m2
-Inadequate protein intake related to altered absorption and
digestion from recent bariatric surgery as evidence by an
increased estimated protein need of 127-159 g/ per day
● INTERVENTION:
-Proper education on nutrition related topics in regards to bariatric
surgery to inform the patient on what foods/ amounts and how frequently
he can consume them. Educate the client on the progression-based diet
that will be implemented in his life post-surgery, such as the Stage 1 and
2 liquid diet for bariatric patients. Educate Mr. McKinley on the foods to
avoid such as complex carbs, processed foods and high fat/ sugar and
sodium content foods.

-Implement physical activity into his daily life, once he is allowed

to start moving again post-surgery. By incorporating physical activity into
his daily life Mr. McKinley can keep the weight off and also keep his risk
of hypertension, CAD/ CHD, hyperlipidemia, type 2 diabetes and other
medical conditions at a lower percentage

● MONITORING AND EVALUATION:

-Have the client maintain a food log in order to track his type of
food, the amount he is consuming and how frequently he is eating in a
day in order to make sure the foods are compliant with his new diet and
reduce his effect of developing dumping syndrome
-Have the client maintain a physical activity log in order to track his
progress and monitor his weight loss

-At the follow up appointments I would want to monitor weight loss

percentage and see his rate of weight loss

-Retake biochemical lab levels to monitor and see if there is any change
in his previously abnormal levels of LDL, HDL, TG, cholesterol, glucose,
HbA1c, potassium and HDL/LDL ratio
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