Obesity Case Study

Obesity Treated With Surgery

Farhyio Barkedle
David Ma
Kerry Samuel
Table of Content
• Introduction
• Risk factors of obesity
• Management
• Case study of Mr. Y and relevant
information
• Future approaches
• Conclusion
What Is Obesity?
• A medical condition in which
excess body fat has accumulated to
the extent that it may have an
adverse effect on health, leading to
reduced life expectancy and
increased health problems (WHO)
The Risks
Rates Hitting Plateau

http://www.nytimes.com/2010/01/14/health/14obese.html
WHY IS THERE AN EPIDEMIC
OF INCREASING OBESITY?
• Cheaper foods
• Advertising & promotion
• More fatty & more snack foods
• More labour-saving machinery at work
• Television
• Personal computers
• More cars
• Less walking/cycling
• Less open space for
recreation
Steps to Treating Overweight and
Obesity in the Primary Care
Setting
• Measure height & weight
• Measure waist circumference
• Assess co morbidities
• Is the patient ready & motivated
• Which diet to recommend
• Discuss a physical activity goal
Management
• WIEGHT LOSS
• For patients with a BMI 30 & for patients
with a BMI between 25 and 29.9 OR a
high-risk waist circumference, and two or
more risk factors.

• An initial weight loss of 10% of body

weight achieved over 6 months is a
recommended target. The rate of weight
loss should be 1 to 2 pounds/week.
Dietary Therapy
• Reductions of 500 to 1,000 kcal/day will
produce a recommended weight loss of 1
to 2 pounds per week.
• likely to be successful when:
– the patient’s preferences are taken in
account
– patient is educated about food
composition, labeling, preparation,
and portion size.
Physical Therapy
• increases energy expenditure
• reduces the risk of heart disease
more than that achieved by weight
loss alone.
• help prevent the decrease in
muscle mass often found during
weight loss.
Behavior Therapy
• Is useful adjunct to planned
adjustments in food intake and
physical activity
– self-monitoring, stress management,
stimulus control, problem-solving,
contingency management, cognitive
restructuring, and social support.
Pharmacotherapy
Weight Loss Surgery
Surgery is an option for well-informed
and motivated patients who have
clinically severe obesity (BMI ≥ 40)
or a BMI ≥ 35 and serious co-morbid
conditions

http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf
 A little about our client...
• Name: Mr. Y
• Age: 35 yrs
• Height: 6 feet 1 inch
• Weight: 350lbs
 Data and History
o Macrosomia – excess wt from birth
o Hx of wt cycling & “yo yo” dieting
o Increased appetite before bed
o High stress level
o SOB & difficulty accomplishing basic tasks (tying
shoes)
o Never participated in regular exercise program
o FHx of maternal diabetes & subsequent heart attack
secondary to obesity (mother died at 55)
o Pristiq – medication for anxiety & depression
o Total cholesterol: 230mg/dl and HDL: 40mg/dl
Ideal Body Weight (IBW): 175.8lbs

IBW: Male = 50kg + 2.3kg for each ins over 5ft

= 50kg + (2.3x13)
= 50 + 29.9
= 79.9kg (175.8lbs)
Adjusted Body Weight (ABW): 229.5lbs

ABW = IBW + 0.4 (Actual wt – IBW)

= 175.8 + 0.4 (310 – 175.8)
= 175.8 + 53.68
= 229.5lbs
Body Mass Index (BMI): 46

BMI = wt (lb) x 703

Ht (in)²

= 350 x 703
(73)²
= 246050 = 46
5329
Classification BMI category Risk of developing
health problems

Underweight <18.5 Increased

Normal weight 18.5 – 24.9 Least
Overweight 25 – 29.9 Increased
Obese
Class I 30 – 34.9 High
Class II 35 – 39.9 Very high
Class III >40 Extremely high
 Harris Benedict Equation Using
IBW
BMR = 66.5 + (13.7 x wt in kg) + (5 x ht in cm) – (6.8 x age)

= 66.5 + (13.7 x 79.74) + (5 x 185) – (6.8 x 39)

= 66.5 + 1094.64 + 925 – 265.2

= 1820.94 kcal x 1.2

= 2185 kcal/day
 Harris Benedict Equation Using
ABW
BMR = 66.5 + (13.7 x wt in kg) + (5 x ht in cm) – (6.8 x age)

= 66.5 + (13.7 x 104.3) + (5 x 185) – (6.8 x 39)

= 66.5 + 1428.91 + 925 – 265.2

= 2155.21 kcal x 1.2

= 2586 kcal/day
HBE Using Current WT

= 66.5 + (13.7 x wt in kg) + (5 x ht in cm) – (6.8 x

age)
= 66.5 + (13.7 x 159) + (5 x 185) – (6.8 x 39)
= 66.5 + 2178.3 + 925 – 265.2
= 2904.6 kcal x 1.2 (activity factor)
= 3485 kcal/day
Recommended calories for weight loss pre-
surgery

A reasonable weight loss for Mr. Y is

1 - 2lbs per week.

Daily caloric intake to lose 1lb per week

= 3485kcal – 500kcal
= 2985kcal
Estimated energy needs = 3485kcal per day

Estimated protein needs:

% of total energy needs = 10-35%

Needs in kcal = 348.5 – 1219.75 kcal
Grams of daily protein needed = 87g to 304g

0.10 x 3485 = 348.5

0.35 x 3485 = 1219.75

4kcal = 1g
348.5 = 87g 1219.75 = 304g
4 4
Pre-surgical actual energy intake = 4200kcal

Pre-surgical actual protein intake = 123 g

Nutrition Care Plan
 Nutrition Care Plan
o Focus on health rather than weight
o Setting small, realistic goals
o Let him feel that he has some control
o No food restrictions
o High caloric food in small portions
o Collaborative care eg. Psychiatrist
 A Day In The Life…
Breakfast
o Scrambled eggs (3) – with butter (1T) and milk (2t)
o 2 sausage links or pieces of fried bacon
o 2 Hash-browns
o 1 cup of coffee (16 oz) with cream (1T) and sugar (1 t)
o Doughnuts & muffins

o Snickers chocolate bar a few times a week

o “Nibbles on snacks” all day long

o “Sips” on coffee (with cream & sugar) all day long
o Sometimes “nibbles” on a can of roasted nuts throughout the
week
 A Day In The Life…
Lunch
o Foot long meatball sub
o Bag of potato chips & chocolate chip cookie
o Large cola to “add some zip to the rest of the day”

Dinner
o Frozen dinners (8 oz or more of meat as roast with gravy, fried
chicken or fried fish)
o Potatoes, rice or macaroni
o Bread and butter
o Several glasses of frozen concentrated juice (assorted
flavours; sweetened)
o Ice-cream
 A Day In The Life

After-dinner snack
o Popcorn (salted with melted butter), peanuts
or cookies
o A couple of canned beers to “help him relax
before bed)
o A 2nd bowl of ice-cream for “added nutrients”
Mr. Y’s Diet - Deficiencies
• Fruits and Vegetables
• Fiber – soluble and insoluble
• Vit A
• Vit C
• Vit E
• Folate
• Dairy products
• Calcium
Mr. Y’s Diet - Excesses
• Unhealthy snacks
• Fat
• Sugar
• Frozen dinner
• Salt
• Fat
• Coffee
• caffeine
 Nutrition Facts of Mr. Y's Usual Daily Diet
Dietary
Serving Cal. Total Fat Trans Chol. Sodium Fiber Protein Vit A (%
Product Size Calories From fat (g) Sat. fat Fat (mg) (mg) Carb. (g) (g) Sugar (g) (g) DV) Vit C Calcium Iron
Roasted
Peanuts 28 g 170 126 14 (22%) 2 (10%) 0 0 198 (8%) 5(2%) 2(8%) 2 8 0 0 2 2

Potato chips 227g 1217 692 79 (121%) 12 (62%) 0 0 18 (1%) 120 (40%) 11 (44%) 0 16 0 118 5 21

Foot-long
meatball
sub 758 1160 400 46 18 2 90 3060 140 18 32 48 80 120 40 50

commerciall
y prepared
chocolate
chip cookie 12g 57 25 3 (4%) 1 (6%) 0 0 36 (1%) 8 0 4 1 0 0 0 1
large cola 32 fl oz 267 1 0 0 0 0 29 (1%) 69 (23%) 0 65 1 0 0 1 4

scrambled
eggs 2 199 137 15.2 (23%) 5.8 (29%) 400 (133%) 211 2 0 1.5 13 13 5 5 14
butter 1 tsp 102 102 11.5 7.5 0 31 82 0 0 0 0.1 7 0 0 0

fried bacon 8.5 g 40 27 3 1 0 10 160 0 0 0 3 0 0 0 2

sausage 1 link 44 33 3.7 1.2 0 11 97 0 0 0 2.5 0 0 0 1

hash brown 78g 170 81 9 3.5 0 0 27 21.9 1.6 1.2 2.5 0 8 1 7

Ritz Cheese
crackers 39g 200 99 11 2.5 0 5 400 22 1 4 3 0 0 8 6

frozen
concentrate
d juice 250g 120 0 0 0 0 0 5 27 1 23 2 2 100 2 2

frozen
dinner (8 oz
meat) 300g 370 153 17 6 0 35 970 38 3 10 17 0 0 4 6
ice cream 79g 145 71 7.9 4.9 0 32 58 17 0.5 15.3 2.5 6 1 9 0

ranch
dressing 2 tbsp (29g) 148 140 15.6 2.4 0 8 287 1.3 0.1 1.2 0.4 0 0 1 0

bread slices 1 slice (25g) 67 7 0.8 0.2 0 0 170 12.7 0.6 1.1 1.9 0 0 4 5

Snickers
chocolate 1 bar
bar (23.5g) 100 27 3 1.7 0 0 70 16 1 9 1 0 0 20 0
 Cal. Sodiu Dietar
Produc Servin Calori From Total Sat. m Carb. y Fiber Sugar Protei Vit A Calciu
t g Size es fat Fat (g) fat (mg) (g) (g) (g) n (g) (% DV) Vit C m Iron

fried
bacon 8.5 g 40 27 3 1 160 0 0 0 3 0 0 0 2

Potato 79 12 18 120 11
chips 227g 1217 692 (121%) (62%) (1%) (40%) (44%) 0 16 0 118 5 21

ice 7.9 4.9

cream 71 145 71 (12%) (24%) 58 17 0.5 15.3 2.5 6 1 9 0

frozen
dinner
(8 oz 17 6 970
meat) 300g 370 153 (26%) (30%) (40%) 38 3 10 17 0 0 4 6

large 29 69
cola 32 fl oz 267 1 0 0 (1%) (23%) 0 65 1 0 0 1 4
Mr. Y’s Diet – Quality and Quantity
• Needs more nutrient dense foods
• Fresh and unprocessed

• Needs less energy dense foods

• Reduce calories intake and other undesired substances
Suggested Alternatives
• Substitute fruits and vegetables for snacks
• Drink water or 100% juice instead of
concentrated beverages
• Cook for himself – healthier than frozen
dinner and increase energy output
• No food before bedtime
Types of Obesity Surgeries I
• Restrictive Surgery – Restrict food intake
amount by using bands or staples.
• Vertical Banded Gastroplasty (VBG)
• Laproscopic Gastric Banding (Lap-Band)
Types of Obesity Surgeries II
• Combined Restrictive and Malabsorptive
Surgery – like the name, it’s a combination of
restrictive and malabsorptive surgeries.
• Roux-en-Y Gastric Bypass (RGB)
• Biliopancreatic Diversion (BPD)
Restrictive Surgery
• Vertical Banded Gastroplasty (VBG)
– Surgically creating a stomach pouch with bands and staples to prevent
large amount of food from entering stomach at once.
– Most common type of surgery.

Pros
– Expect quick weight drop
– Allow natural nutrient absorption

Cons
– Antiquated procedure
– Rare complications such as
» Stenosis, aka band stricture
» Dehiscence, aka staple failure
Restrictive Surgery
• Lap-Band – use only a band to create a small stomach pouch
and restrict the amount of food can be ingested.

Pros
– Least hospitalization time
– Quickest recovery time
– Reversible

Cons
– Rare and minor problems
Combined Restrictive and Malabsorptive
Surgery
• Roux-en-Y Gastric Bypass (RGB)
– Most common bypass procedure
– Also involve a stomach pouch
– A direct connection from the pouch to ileum or jejunum to produce
malabsorption

• Pros
– Effective
• Cons
– Nutrition deficiency
– Leakage
Combined Restrictive and Malabsorptive
Surgery
• Biliopancreatic Diversion (BPD)
– Most complicated surgical procedure
– Typically involve the removal of part of the stomach
– Usually only used for people with BMI > 50
– The remaining section of the stomach is connected to ileum for
malabsorption

• Cons
– Malnutrition
– Where is my stomach?
– Appetite?
– Leakage etc.
Positive Surgery Outcomes

• Significant long term weight loss (average

61.2%)
• Recovery from diabetes (77% no longer
require medications)
• Improvement on CVD risk factors
• Possible lifestyle changes
Complications of Surgery

• < 10 % operative complications

• 1% mortality rate for healthy individuals with
BMI < 50
• 2% mortality rate for individuals with diseases
and BMI > 60
• Gastric dumping syndrome
• Late complications are uncommon
Follow up

• Revisit within 2-4 weeks

• Monthly visits for the initial 3 months
• Closely monitor everything
 Post-Surgical Dietary Suggestions

The first 3 months…

Not allowed to eat for one to two days after

surgery
 Phases of Post-Surgery Diet
Progression
Liquids
o Foods & fluids that are liquid or semi-liquid at room temp. &
contain mostly water.
o Usually lasts 1 to 2 days

Pureed foods
o Foods with a consistency of a smooth paste or a thick liquid.
o Usually lasts 3 to 4 weeks or as recommended by dietitian or
doctor

Soft foods
o Foods that are tender & easy to chew
o Followed for 8 wks before progressing to regular foods.
 Progression
o Many small meals

o Sip liquids slowly throughout the day (not with

meals)

o 6 meals  4 meals  3 meals per day

o High protein
 Life Long Changes: New Eating
Habits
o Eat small amounts
o Eat & drink slowly
o Chew food thoroughly
o Drink liquids between meals
o Try new foods one at a time
o Take recommended vitamin & mineral
supplements
Post-surgical physical activity
Recommend for Mr. Y

• Walking for about twenty minute

each morning
• Travel whenever possible by foot
• A weight loss surgery support group
The Benefits of Physical Activity

• Increased Self-Esteem
• Decreased Risk of a Heart Attack
• Decreased Risk of Osteoporosis
• Increased Strength and Stamina
• Reduced Depression
Is Surgical Intervention The Only Way To
Diminish The Obesity Epidemic In North
America?
• No!
• Complications include:
• risk of infection,
• obstruction of the outlet
• development of blood clots in the legs or
lungs, bleeding, metabolic or nutritional
deficiencies
• recurrent vomiting.
• vitamin (especially vitamin B-12) and mineral
deficiencies resulting in anemia or
osteoporosis
 SOAP Guidelines
Subjective

• Mr. Y has always been overweight.

• He is frustrated with dieting and has anxiety

and depression.

• He reported increased appetite before bed,

increased SOB and difficulty doing basic
physical tasks.
 SOAP Guidelines
Objective

• Ht = 6feet 1 inch Wt = 350lbs

• IBW = 175.8 lbs

• Total cholesterol: 230mg/dl HDL: 40mg/dl

• Use of Pristiq medication

 SOAP Guidelines
Assessment

• Present intake is excessive and physical

activity is inadequate.

• 2985kcal to lose 1lb per week.

• Hypercholesterolemia
 SOAP Guidelines
Plan

• Lab tests for diabetes and heart function.

• Long term goal: change lifestyle habits to lose
at least 35 lbs in a 6 month period.
• Instruct on lower fat food choices and small
portion sizes.
• Client will keep a daily food and mood record
to review next session.
• Follow-up in one to two weeks.
 Future Approaches

• Obesity prevention should take a multi sector approach

• Innovative ways to provide access and programs to less economically

viable citizens should be developed

• health care professionals should assess readiness and barriers to

change

• Primary care health professionals should work with other health care
team members to develop a comprehensive weight management
program

 
Summary and Conclusion
• Pre-surgical diet and lifestyle were too
unhealthy

• Surgical intervention is necessary to

achieve immediate improvement

• Need to adopt better post-surgical diet

and lifestyle for long term health
 References
http://www.healthalternatives2000.com/minerals-nut
rition-chart.html

http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_
b.pdf

http://
www.slideworld.org/slideshow.aspx/Overweight-a
nd-Obesity-ppt-2843205

http://
www.healthalternatives2000.com/vitamins-nutritio
n-chart.html
Thank You

Questions?