Hailey Westenbroek, Aarica Geitner, Pedro Guzman, Ricky Licona

Case Study #2 Bariatric Surgery for Morbid Obesity

1. Define the BMI and percent body fat criteria for the classification of obesity. What BMI is
associated with morbid obesity? Classification BMI range for obesity is a range of 30.0-
34.9kg/m2(class1 obesity).BMI range associated with morbid obesity is a BMI of 35kg/m2 (class
2) or higher. Body fat percentage ranging from 20-25% or more in males, and 25-32% or more in
females is deemed excessive and can cause health risks.

2. List 10 health risks involved with untreated morbid obesity. What health risks does Mr.
McKinley present with? Chronic diseases such as heart disease, type 2 diabetes, hypertension,
stroke, gallbladder diseases, infertility, sleep apnea, cancer, arthritis (osteoarthritis),
depression/mental health complications. Currently, Mr. McKinleys health risk are: type 2
diabetes, 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 allotted to patients that depict a BMI of 40kg/m2 or
greater, as well as having a BMI of 35kg/m2 if they present comorbidities. Mr. McKinley
currently has a BMI of 58.8kg/m2 which classifies him as a morbidly obese individual allowing
him to qualify for Bariatric surgery.

5. Describe the following surgical procedures used for bariatric surgery, including advantages,
disadvantages and potential complications.

a. Roux-en-Y gastric bypass:

This type of surgery is the most common malabsorptive procedure as well as the most
common type of bariatric procedure. The jejunum is pulled and anastomosed to the
esophagus. The duodenum is then connected to the small bowel so that the bile and
pancreas secretions can flow into the intestine.
Advantages:
-Produces significant long-term weight loss (60 to 80 percent excess weight loss)
-Restricts the amount of food that can be consumed
-May lead to conditions that increase energy expenditure
-Produces favorable changes in gut hormones that reduce appetite and enhance satiety
-Typical maintenance of >50% excess weight loss
Disadvantages:
-Possibility of vitamin and mineral deficiency
-Typically longer hospital stays than other
-There can be nutrient deficiencies for vitamins A, D, E and K, vitamin B12, folate,
potassium, magnesium, iron, and calcium
-Some patients may experience dumping syndrome, tachycardia, sweating and abdominal
pain
-Requires adherence to dietary recommendations, life-long vitamin/mineral
supplementation, and follow-up compliance
Potential complications:
Hailey Westenbroek, Aarica Geitner, Pedro Guzman, Ricky Licona

-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 cuts 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. It is
important to note that this procedure does not involve cutting/changing sphincter muscles
that allow food to enter/leave the stomach.
Advantages:
-Restricts the amount of food the stomach can hold
-Minimal nutrient malabsorption
-By leaving the pylorus intact it reduces the possibility of the patient developing dumping
syndrome
-Short hospital stay, approx. 2 days
Disadvantages:
-This procedure relies more on the decrease in food intake prior to surgery, so there is a
possibility of weight regain
-Most complicated procedure and is nonreversible
-Only performed on patients with the highest surgical needs due to high BMI value
-Has potential for log term vitamin deficiency
Potential complications:
-Infection associated with surgery

c. Adjusting gastric banding:

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 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:
-Reduces the amount of food stomach can hold
-The 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
-The highest rate of reoperation
-Can have mechanical problems w/ band, tube or port in a small percentage of patients
-Can result in dilation of the esophagus if the patient overeats
Potential complications:
-If the band falls off/slips off then another procedure would need to be performed to
adjust it
-Infection associated with surgery
Hailey Westenbroek, Aarica Geitner, Pedro Guzman, Ricky Licona

d. Vertical banded gastroplasty:

Gastroplasty reduces the size of the stomach by applying rows of stainless steel staples to
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 the patient consumes too much food, it can cause nausea or vomiting due to the
smaller size stomach
Potential 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, 60-70%
-Reduces the % of fat by 70% or more
Disadvantages:
-Higher risk surgery and most aggressive procedure
-Longer hospital stay, a higher rate of mortality
-More likely to cause protein deficiency
Potential 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:
-The greatest amount of weight loss
Disadvantages:
-Performed on patients with a BMI of 50 kg/m2 or higher
-Nutrient deficiencies and protein malnutrition
Hailey Westenbroek, Aarica Geitner, Pedro Guzman, Ricky Licona

Potential 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. But according to WebMD, there was a
study done with 400 patients and 62% did not have diabetes after undergoing bariatric surgery.
Restrictive-malabsorptive procedures are most effective in treating T2DM patients based on
changes induced in appetite through regulation of gastrointestinal hormones, with decreased
hunger and increased satiation. 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, 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.

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.

BMI: 410#/70in2 x 703 = 58.8 kg/m2 (Class 3, High risk obesity)

%UBW: 410#/434# x 100= 94.5%

IBW: 106# + (6# x 10)= 166#

AW: 166# + 0.4(410-166)=263.6#

Because Mr. McKinley has not weighed less than 250# since he was 15 years old, his ideal body
weight is not realistic. A more reasonable goal weight for Mr. McKinley would be his adjusted
body weight of 263.6#.

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.

25kcal x 119.8kg = 2995kcal, 30kcal x 119.8kg = 3594kcal (using Adjusted weight)

Protein: 1.0g x 186.3kg = 186g, 1.2 x 186.3kg = 224g (using actual weight)

Energy requirements were determined using Mr. McKinley’s adjusted body weight to ensure he is
not being overfed. Protein requirements were calculated using Mr. McKinley's actual body
weight to ensure they are not being underestimated by using adjusted weight and to preserve
LBM during weight loss.
Hailey Westenbroek, Aarica Geitner, Pedro Guzman, Ricky Licona

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

1. Morbid obesity (NC-3.3.5) r/t food-and nutrition-related knowledge deficit AEB BMI >
40kg/m2 (58.8 kg/m2).

2. Excessive fat intake (NI-5.5.2) r/t food- and nutrition-related knowledge deficit concerning
appropriate amount of dietary fat AEB cholesterol >200mg/dL ( 320mg/dL), HDL <50mg/dL
(32mg/dL), LDL >130mg/dL (232mg/dL) and TG >160mg/dL (245mg/dL).

16. Determine the appropriate progression of Mr. McKinley’s post-bariatric-surgery diet.

Include recommendations for any supplementation that should be prescribed.

Mr. McKinley is starting with the Stage 1 Bariatric Surgery diet. The diet begins with clear
liquids only, to full liquid, then it progresses to pureed foods, soft foods, and eventually regular-
textured foods with an emphasis on protein. Sample foods are broth, pureed soft meats or fruits,
foods that can be mashed with a fork like cooked vegetables. Dehydration is the most common
reason for readmission so it’s equally important to remain properly hydrated. Dumping syndrome
from rapid bowel evacuation can occur with high carbohydrate intake or voluntary excessive food
intake, and these diets help alleviate and minimize related symptoms like diarrhea, nausea, light-
headedness, and fatigue. Food tolerance records help in devising appropriate programs. Caffeine
should be avoided in the first 30 days and protein should be spread out across the day to preserve
lean body mass.

Because there is reduced intake and digestion of food from a shortened GI tract, less absorption
of calories and nutrients is likely and micronutrient deficiencies can occur. Life-long
supplementation of fat-soluble vitamins ADEK, B12, folate, thiamin, potassium, iron, calcium,
zinc, copper, and magnesium is key where needed. We recommend that Mr McKinley take a
chewable multivitamins, and supplements for D (400-2000 IU), calcium citrate (1200-1500 mg),
folic acid (400 mg), elemental iron (65-80 mg with Vitamin C), and B12 (500 mcg). ADEK
depending on the vitamin malabsorption degree of his surgery.

20. From the literature, what is the success rate of bariatric surgery? What patient
characteristics may increase the likelihood for success?

Bariatric surgery is the current gold standard of the weight loss surgeries. The NIH recognizes
that this is the “only effective treatment to combat severe obesity and maintain long-term weight
loss.” Success rate for previously severe obese individuals is at 90+% at maintaining 50+% of
excess wieght loss after surgery. For those who had super severe obesity, 80+% maintain the
same 50+% of excess weight loss. One study found that mortality rates dropped by up to 89%
when comparing surgery individuals with similar obese indivuduals without surgery over a 5-year
period. Diabetes-related deaths between the two groups was found to have a 90+% reduction and
50+% reduction in heart disease.
Hailey Westenbroek, Aarica Geitner, Pedro Guzman, Ricky Licona

Mortality rates for the bariatric surgery itself sits at 3/1000 which is similar to gallbladder
removal, yet less than a hip replacement. Up to 16% of patients may experience complications
and high risk of malnutrition will require lifetime monitoring. Given that most qualified patients
have 1 or more life-threatening diseases at the time of surgery, the benefits far outweigh the
complication risk. Comorbidities that can be improved include Type 2 DM (80% remission,
85+% improvement), hypertension, dyslipidemia, and more.

A patient is more likely to succeed if they attend follow-up visits with their surgical team and
RD(N), join a support group, and adopt healthy lifestyle choices--engage in 60-90 minutes of
physical activity a day, weighing themselves regularly to monitor progress, and adherence to a
low-fat diet (24% of total kcal), and eating breakfast every day. Two support groups geared
towards these patients are Overeaters Anonymous and Take Off Pounds Sensibly. Monotonous
diets can be helpful to control intake. “Keep the ‘extras’ to no more than 200 kcal per day.”