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Julia Werth
Medical Nutrition Therapy 1
Professor Jill Wanik
Honors Conversion

Case 2 Bariatric Surgery for Morbid Obesity

1. Define the BMI and percent body fat criteria for the classification of morbid obesity. What
BMI is associated with morbid obesity?
Individuals with a BMI above 40 fall into the classification of morbid obesity. The body fat percentage
must also be over 30 percent for women and 25 percent for men in order to fit in this category.

2. List 10 health risks involved with untreated morbid obesity. What health risks does Mr.
McKinley present with?
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

Stroke
Coronary heart disease
Cancer
Sleep apnea
Gout
Osteoarthritis
Gall bladder disease
Nonalcoholic fatty liver disease
Pulmonary disease
Type 2 diabetes mellitus

Mr. McKinley presents type 2 diabetes mellitus, hyperlipidemia, hypertension and osteoarthritis.

3. What are the standard adult criteria for consideration as a candidate for bariatric surgery?
After reading Mr. McKinleys medical record, determine the criteria that allow him to qualify
for surgery.
To be considered as a candidate for bariatric surgery a patient must have a BMI over 40 or have a BMI
between 35 and 39.9 and present other cofactors such as life-threatening cardiopulmonary disease, severe
diabetes or lifestyle impairment. The patient must also demonstrate failure to achieve adequate weight loss
with nonsurgical treatment.
Mr. McKinley qualifies for surgery because he is morbidly obese (BMI of 59) and he has type 2 diabetes
and risk factors for cardiovascular disease including hyperlipidemia and hypertension. He has also tried to
lose weight several times but never been successful in keeping it off.

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 Penn Metabolic and Bariatric surgery program requires all candidates to undergo a thorough
evaluation which includes a pre-operative psychology screening The personnel involved in the program

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include MD/FACS, nurses, dietitians and psychologists who all specialize in weight loss and bariatric
surgery.

5. Describe the following surgical procedures used for bariatric surgery including advantages,
disadvantages, and potential complications.
a. Roux-en-Y gastric bypass
i. A restrictive and malabsorptive surgical technique that staples a new
smaller stomach pouch and cuts the small intestine and reattaches it to the
new smaller stomach. The surgery can be done laparoscopically or with an
open incision depending upon the patients girth, previous surgeries and
medical history. The Roux-en-Y results in rapid weight loss over the first
year and slowed but continual weight loss over the next six months. It is
an irreversible surgery, however, that results in a lifelong diet change and
vitamin/mineral absorption complications often resulting in iron
deficiency anemia and vitamin B12 deficiency. The surgery also increases
the risk of ulcers at the junction of the stomach and jejunum.
b. Vertical sleeve gastrectomy
i. The vertical sleeve gastrectomy is used for patients with BMIs over 50 and
multiple co-morbidities. It is a very common, restrictive procedure that
cuts off between 60 and 85 percent of the stomach making digestion more
difficult since access to parietal and chief cells is blocked. It is a safer
procedure and produces better weight loss results than gastric banding.
c. Adjustable gastric banding (Lap-Band)
i. The laparoscopic adjustable gastric band surgery is the least intrusive
surgical option and can be reversed. However, it results in only about 40 to
50 percent weight loss, which is much less than gastric bypass and a little
lower than the sleeve gastrectomy. This surgery has the lowest mortality
rate, operative complication rate and malnutrition risk. However, it
requires regular follow-ups to adjust band tightness.
d. Vertical banded gastroplasty
i. Vertical banded gastroplasty (stomach stapling) is a restrictive surgery
where the staple techniques of the sleeve and the band from the gastric
banding surgery. It is irreversible because a hole is cut in the stomach.
This surgery has a shorter hospital stay than other procedures and just over
1 percent of patients have major complications, but typically results in less
overall weight loss. The advantage to this procedure is no dumping
syndrome or nutritional deficiencies/malabsorption occurs. The downside
is that compliance with a very strict diet is necessary and thorough
chewing of all food is required.
e. Duodenal switch and biliopancreatic diversion (BPD/DS)
i. The duodenal switch procedure is both a restrictive and malabsorptive
surgery. In the surgery 70 percent of the stomach and the majority of the

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duodenum are removed and a digestive loop and biliopancreatic loops are
created. The two loops converge into a common channel where the food
and bile end up mixing. The advantage to the duodenal switch surgery is
that it results in higher weight loss and it generally cures patients who
previously had type 2 diabetes. Patients must take vitamin and mineral
supplements for the rest of their lives after surgery because they would
become deficient in vitamins A, D, E and K.
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?
After surgery patients experience a normalization of plasma glucose concentrations, insulin and H1c.
These effects occur due to the weight loss, but also because of the reduced calorie consumption, partial
malabsorption of nutrients and restructuring of the GI tract which causes alterations in the incretin system
which affects glucose balance.
Most medical conditions are improved by weight loss including arthritis, obstructive sleep apnea and high
blood pressure, many of which Mr. Miknley displays.

7. How does the Roux-en-Y procedure affect digestion and absorption? Do other surgical
procedures discussed in question #5 have similar effects?
The Roux-en-Y procedure often results in micronutrient deficiencies of B12, thiamine, folate, iron,
calcium and vitamin D. Protein is also often a concern since directly following surgery calorie intake is so
low and there is a lack of HCL/Pepsinogen.
Many of the procedures including adjustable gastric banding, sleeve gastrectomy and biliopancreatic
diversion/duodenal switch result in deficiencies because they limit the space in which or time during
which nutrients/calories can be absorbed.

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 post-surgery to avoid dumping syndrome which can occur when high sugar food
empties rapidly into the intestine and causes an influx of liquid.

9. Over the next two months, Mr. McKinley will be progressed to a pureed-consistency diet
with 6-8 small meals. Describe the major goals of this diet for the Roux-en-Y patient. How
might the nutrition guidelines differ if Mr. McKinley had undergone a Lap-Band procedure?
The goals of the pureed-consistency diet are to incorporate high protein foods in order to aid in pouch
healing, start taking chewable vitamin and mineral supplements and drinking plenty of fluids. The RNY
patient nutrition guidelines differ from those of a lap-band patient because it takes much more time for the

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RNY patient to work up to a normal meal size and the 1000-1200 calorie diet that is ideal for bariatric
surgery patients. Therefore, if Mr. McKinely had gotten the lap-band surgery he would be eating 3 meals a
day instead of six very small meals.

10. Mr. McKinleys 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.
Calcium and iron deficiencies often occur in bariatric surgeries, like the roux-en Y, that involve
eliminating or bypassing a portion of the small intestine because that is the primary site of their absorption.
Vitamin B12 deficiency is seen because the stomach is made smaller in many bariatric surgeries, including
the RNY, which decreases the mechanical digestion as well as acid and intrinsic factor section that are
required to absorb B12.

11. Assess Mr. McKinleys 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.
Mr. McKinley has a BMI of 59. His percent usual body weight is 94.5%. A reasonable weight goal for Mr.
McKinley is 266.5 lbs. It is normal for a patient to lose approximately 65-70 percent of their body weight
after gastric bypass and Mr.McKinley has already demonstrated

12. After reading the physicians history and physical, identify any signs or symptoms that are
most likely a consequence of Mr. McKinleys morbid obesity.
Type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis and the need for a knee replacement
are all likely due to Mr. McKinleys morbid obesity. In addition, Mr. McKinley has pitting edema and a
rash under his skinfolds which is also likely due to his morbid obesity.

13. Identify any abnormal biochemical indices and discuss the probable underlying etiology.
How might they change after weight loss?
A CBC with differentials, comprehensive metabolic profile, PT/PTT, EKG and urinalysis were ordered,
however the results were not reported yet.

14. Determine Mr. McKinleys energy and protein requirements. Explain the rationale for the
method you used to calculate these requirements.
Mifflin St Jeor equation for me: REE = ([10 X 186.4] + [6.25 X 177.8] [5 X 37] 166) X 1.2
REE = (186.4 + 1111.25 185 166) X 1.2
REE = 1135.98 calories
To calculate Mr. McKinleys energy requirement the Mifflin St. Jeor equation along with an injury factor
of 1.2, which is typically used for surgery patients, was used.

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After the operation protein intake must be increased to promote healing. Normally the recommendation is
between 60 and 80 grams of protein per day. To calculate exact need it is normally 1.0-1.5 grams per
kilogram of ideal body weight. IBW = 50 kg + 2.3 kg (inch over 5ft) = 50 + 2.3(10) = 73kg.
Therefore, Mr. McKinleys protein requirement is between 73 and 109.5 grams per day.

15. Identify at least two pertinent nutrition problems and the corresponding nutrition diagnoses.
Excessive energy intake related to family history of obesity as evidenced by BMI of 59.
Excessive carbohydrate intake related to poor food choices as evidenced by type 2 diabetes mellitus.

16. Determine the appropriate progression of Mr. McKinleys post-bariatric-surgery diet. Include
recommendations for any supplementation that should be prescribed.
Mr. McKinley should begin on a sugar-free clear liquids diet that includes sugar-free jello and broth. He
will stay on that diet for a few days before progressing to an all liquids diet that consists of protein shakes
and low carb drinks for 1-2 weeks. Next he will spend 1-2 weeks on a puree diet then 1-2 weeks on soft
before finally progressing to a regular diet. The diet will consist mostly of protein and produce and to
promote healing, protein supplements may even be required. It is important that Mr. McKinley avoid
dry/tough meats, red meats, fibrous vegetables, doughy bread, pasta and rice that arent fully cooked,
sweets, lactose and fried or heavy food. It is also to maintain a steady fluid intake that limits sugary,
caffeinated or alcoholic beverages. Mr. McKinley should also begin taking supplements, especially
calcium, iron and B12.

17. Describe any pertinent lifestyle changes that you would view as a priority for Mr. McKinley.
It is essential that Mr. McKinley adjust his diet to between 1000 and 1200 total calories a day. It is also
important that Mr. McKinley take care to eat his food in many small meals, normally 6, throughout the day
instead of three larger ones in order to not stretch his stomach pouch back out. Mr. McKinley must also
make taking supplements of B12, thiamine, folate, iron, calcium and vitamin D a regular part of his routine
in order to not develop deficiencies.

18. How would you assess Mr. McKinleys readiness for a physical activity plan? How does
exercise assist in weight loss after bariatric surgery?
Mr. McKinley is between the preparation/action stages of change. He has already demonstrated his
readiness to change in terms of diet and has lost 24 pounds since entering the pre-surgery program. He is
ready to take the next, necessary steps in his process of weight loss and that includes incorporating
physical activity which has been shown to increase weight loss outcomes in bariatric surgery patients by
more than 5 percent, especially when it comes to maintaining weight loss years out.

19. Identify the steps you would take to monitor Mr. McKinleys nutritional status
postoperatively.
To monitor Mr. McKinleys nutritional status postoperatively I would work with the team of medical
professionals involved in Mr. McKinleys care to teach him effective lifestyle change strategies. I
would make sure to stress to him that following up with the healthcare team is very important
including a visit 1 week after, 3 months after, 6 months after, 1 year after, 18 months after and every
year thereafter. At these visits lab work should be done to ensure that Mr. McKinley hasnt developed
any deficiencies and that he has been compliant with his vitamin supplements and has adequate

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protein intake. I would also make sure to review fluid requirements as well as any changes he needs to
make in his eating behavior and physical activity at this point in his recovery.

20. From the literature, what is the success rate of bariatric surgery? What patient characteristics
may increase the likelihood for success?
For the Roux-en-Y, about 85 percent of patients lose and maintain a 50 percent initial excess weight loss.
There is 0.1 percent mortality rate associated with the surgery and a 5 percent chance of serious
complications. In the long term there is a 10 to 15 percent chance that patients will revert back to old
habits and weight.

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?
For a child or adolescent to be considered for bariatric surgery they must have a BMI greater than 35 as
well as other major co-morbidities such as type 2 diabetes mellitus, severe sleep apnea, etc. If the patients
BMI is over 40 then their co-morbidities can be slightly less severe, such as hypertension, insulin
resistance, glucose intolerance, dyslipidemia or moderate sleep apnea.