Case 2.

Bariatric Surgery for Morbid Obesity

Hanna Fleshman, Olivia Echevarria, Jasmine Estrada

Introduction and Objectives

Mr. McKinley is admitted for 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.
Answer the following questions below.
1. Define the BMI for all classes of obesity. (Jasmine)
● Overweight (not obese), if BMI is 25.0 to 29.9.
● Class 1 (low-risk) obesity, if BMI is 30.0 to 34.9.
● Class 2 (moderate-risk) obesity, if BMI is 35.0 to 39.9.
● Class 3 (high-risk) obesity, if BMI is equal to or greater than 40.0.
(Weir & Jan, 2022)
2. List 5 (Not 10) health risks involved with untreated morbid obesity. What health risks does Mr. McKinley
present? (Hanna)
Health risk involved:
1. Premature death
2. T2DM is 3x more prevalent among obese than normal weight; relative risk increases by 25% for each unit
of BMI over 22 kg/m2
3. Cancer
4. HTN is 2x more prevalent among adults with a BMI greater than or equal to 30 kg/m2 compared to normal
weight
5. Arthritis
-for every 2 lb increase, risk of arthritis increases 9-13%
Health risk presented:
1. Morbid obesity osteoarthritis
2. Hypertension due to circulating blood volume and cardiac output
3. Type 2 diabetes mellitus due to insulin resistance
4. Hyperinsulinemia
5. Hyperlipidemia
(Shipley, Powerpoint, 2022)
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. (Hanna)
Standard adult criteria:
1. Have a BMI of 40 or higher or;
2. Have a BMI between 35 and 40 and an obesity-related condition, such as heart disease, diabetes, high blood
pressure, or severe sleep apnea
3. Weigh less than 450 pounds, the maximum weight that hospital radiology equipment can accommodate. If
you need to lose weight to meet this requirement, a nutritionist is available to help.
4. Patient is 18 years or older
5. Failed weight reduction treatments
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 Criteria that qualify Mr. Mckinley:
1. BMI 58.7 which is class 3 obesity(high risk)
2. Suffers from type 2 diabetes, hyperlipidemia, hypertension, osteoarthritis
3. Weighs 410 pounds
4. Patient is 37 years old
(UCSF Health, 2022)
5. Describe the following surgical procedures used for bariatric surgery, including advantages,
disadvantages, and potential complications. (Jasmine)
A. Roux-en-Y gastric bypass:
Procedure:
A small portion of the stomach that is connected to the esophagus is cut from the rest of the stomach and is
stapled shut. This portion is referred to as the ‘new stomach pouch’. The remainder of the stomach is
completely bypassed and stapled shut. The first part of the small intestine, the duodenum is then initially
separated from the jejunum. The beginning of the jejunum is then connected to the new stomach pouch.
Then the lower end of the duodenum meets with the jejunum once again on a lower point to the side. This
new configuration has a Y shape, hence the surgical name
Advantages:
- Small stomach pouch created allows the patient to feel satiated quicker, resulting in decreased
calorie intake and weight loss
- Helpful surgery for those who are obese and struggling to lose weight on their own
Disadvantages:
- Since the part of the small intestine is bypassed (duodenum), the amount of nutrient absorption is
greatly reduced.
Potential complications:
- Leakage along the staple lines of the small pouch and remaining stomach leads to an increased
chance of infections
- Obstruction of the digestive tract due to scar formation
- Dumping syndrome: when food, especially those high in sugar, moves through your stomach down
to your bowels too quick, causing rapid gastric emptying
(Alila Medical Media, 2014)

B. Vertical sleeve gastrectomy

Procedure:
A cut is made vertically down the stomach, completely removing up to 85% of it. The remainder of the
stomach, now considered the new stomach, is stapled shut. This allows for the sphincters
at the end of the esophagus and the beginning of the small intestine to remain. Procedure is irreversible
Advantages:
- Two sphincters are untouched, allowing for digestion and absorption to be minimally affected.
- Reduces the risk of malabsorptive complications
- Aids in weight loss due to decreased stomach sized
Disadvantages:
- Lack of long-term data, not endorsed by Bariatric Surgery societies and not covered by some
insurance companies
- Completely irreversible since excess stomach is removed from the body

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 Complications:
-Leaking along staple lines
- Post-operative bleeding
(Alila Medical Media, 2014)
7. How does the Roux-en-Y procedure affect digestion and absorption? (jasmine)
The small intestine is the main site of absorption. In Roux-en-Y surgery, the beginning of the small
intestine, the duodenum, is completely bypassed resulting in malabsorption of micronutrients. These
micronutrients include vitamins A, C, D, K, thiamine, folic acid, and B12, and minerals including iron,
selenium, zinc, and copper” (Quercia et al., 2014).
Digestion is also impaired since the stomach pouch created is only about 10% of its original size.
(Quercia et al., 2014).
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? (livi)
A. The major goals for Mr. McKinley is to lose weight, lower his BMI, and to avoid eating too much
food while still consuming the necessary nutrients, mainly protein, all while eating small meals in
order to not have dumping syndrome to occur. Avoiding high sugar beverages and foods, drinking
anywhere from 20-48 oz of clear liquids, eating high protein foods, and avoiding overeating.
B. The nutritional guidelines would differ if he had undergone a Lap-Band procedure because the
Roux-en-Y is a bypass of the duodenum and some of the jejunum but a Lap-Band procedure is a
gastric sleeve, so there is no bypass involved, and it is adjustable. Lap-Band does not affect
absorption within the stomach, unlike the bypass, an adjustable procedure, and the nutrition
guidelines are not nearly as strict as the bypass. Lap-Band surgery can accommodate larger meals,
does not change the actual necessary nutrients needed for intake, and will not change the diet habits
of the patient nearly as much.
C. Similarly, the Lap-Band guidelines for post-op are liquid for the first two weeks, then slowly adding
soft foods, then solids, and then a normal diet just slow eating and no beverages 30 minutes before
or after meals. And of course limiting sugar and sodium intake, choosing nutrient-dense options
versus highly processed options, and eating lean protein.
D. (UCSD, Dietary Guidelines After Weight-Loss Surgery)
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. (jasmine)
Weight: 410 lbs → 185.97
Height: 5’10 ft → 177.8 cm → 1.78 m
Current weight: 410 lbs
Previous weight: 434

BMI: weight (kg) / height m^2

—----> 185.97kg/ 1.78m ^2
—----> = 58.7: class 3 high risk extremely obese

% Usual body weight: current body wt/ UBW x 100

—-----------------------> 410 / 434 x 100

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 —-----------------------> 94%

Finding reasonable body weight:

IBW: 106 lbs for 5 foot + 6 lbs per inch over 5 foot or -6 lbs per inch under 5 foot
—---> 106 + (6) 10= 166 lbs

This body weight is not realistic at the moment for the patient.
Method #1
A more achievable body goal weight can be found by adjusting [Link]’s weight measurement to find
a BMI that would result in <30; that way he would no longer be categorized as obese.
I plugged in several different weights into the BMI calculation to find the weight that would ensure
[Link]’s position in the overweight but not obese category

Calculations:
BMI: weight (kg) / height m^2

Trial #1
Weight: 200 lbs → 90.72 kgs

Eqn: 90.72 kg/ 1.78^2= 28.6 X

Trial #2
Weight: 205 lbs → 92.99 kgs
Eqn: 92.99/ 1.78 ^2= 29.4 X

Trial #3
Weight: 209 lbs → 94.80 kgs
Eqn: 94.80/ 1.78 ^2 = 29.9 or 30 ✓

Method #2

Another method is to account for the weight loss that will occur after surgery (typically 20-35% within the
first 2-3 years post-operation). Textbook. This means that [Link] would be losing 82-144lbs, , along
with additional weight loss as a result of dietary and lifestyle changes recommended by RD.

Conclusion based on both methods:

Therefore, a reasonable and achievable weight goal for Mr. McKinley after 2 years post-op would be
around 275 lbs, with the ultimate goal of reaching below 209 lbs as the years pass.
(Shipley, Powerpoint, 2022)
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. (Jasmine)
Energy requirements:

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 MSJ (MALE)→RMR = (10 X wt in kg) + (6.25 x ht in cm) – (5 x age) + 5

Weight: 410 lbs → 185.97kg

Height: 5’10 ft → 177.8 cm
Age: 37

(10 x 185.97 kg ) + (6.25 x 177.8) - (5 x 37) +5

=2791 kcal
=2791 x 1.3 (sedentary)
=3628 k/cals a day to MAINTAIN weight

Post surgery, stomach capacity will decrease. Which means less calorie intake will be needed which will
further assist in weight loss

IBW= 166 lbs → 75 kg

20-35 kcal/kg IBW for obese pt

(20-35) cal per IBW x 75 kg

=1500 - 1875 k/cal per day for weight loss post surgery

Protein Requirements:

A diet high in protein is recommended to speed up the healing process

Recommended RDA while healing post surgery : 1.0- 1.3 g/kg
1.0 - 1.3 x 75 kg = 75-97 g protein/day

Recommended RDA for weight loss: 0.8 – 1.0 g/kg

0.8 – 1.0 g/kg x 75 = 60 - 75 g of protein/ day
(Shipley, Powerpoint, 2022)
15. Identify at least two pertinent nutrition problems and the corresponding nutrition diagnoses. (PES
statement)(Hanna)
Pertinent nutrition problems:
1. Excessive energy intake
2. Type 2 diabetes, hyperlipidemia, hypertension, osteoarthritis

PES Statement:
Excessive energy intake is related to type 2 diabetes, hyperlipidemia, hypertension, and osteoarthritis as
evidenced by class 3 obesity.
(Shipley, Powerpoint, 2022)
16. Determine the appropriate progression of Mr. McKinley’s post–bariatric-surgery diet. Include
recommendations for any supplementation that should be prescribed. (livi)
a. According to Tufts, there are 5 stages of post Roux-en-Y surgery.
b. Stage 1: usually the day of or following the surgery is a clear liquid only diet. This would consist of
water, sugar free flat beverages that are clear, bouillon, or sugar free gelatin.
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 i. Recommended 1 oz of water per hour
c. Stage 2: usually paired with stage 1 and consists of sugar free flat beverages (ginger ale), bouillon,
or sugar free gelatin.
i. Recommended 3 oz of bouillon or gelatin 3 times a day.
d. Stage 3: 2-3 weeks, the stage after being discharged. Consists of high protein and full liquids. Some
of the options for protein include: egg whites, protein shakes made with skim milk, soup made with
skim milk, etc. Some options for full liquids include: water, crystal light, flavored waters, fat free
low sodium broth, decaf coffee, etc.
i. Recommended: at least 64 oz of fluid, 60-70 grams of protein DAILY
e. Stage 4: After the 2 week post-op checkup. Consists of protein, liquids, and supplements. Some
options for proteins: ground meat (must be >93% fat free), turkey chili, fatty fish, etc. Some options
for liquids: see above.
i. Recommended: at least 64 oz of liquids, 60-70 grams of protein (EAT PROTEIN FIRST
WITH MEAL), and supplements DAILY
ii. Supplements: daily multivitamin with iron added (must be chewable and 200% of DV),
calcium with vit. D (1200-1500mg, also chewable), B12 sublingually (1000 mcg), and D3
chewable (1000 IU). All must be taken daily.
f. Stage 5: starting at least 6-8 weeks post-op, low fat, low sugar, high protein. High protein foods
include: fish like cod or salmon, lean ground meat with less than 3% fat, skinless chicken and
turkey, etc. Low sugar foods would be diet jello or popsicles. Low fat foods include: fat free
mayonnaise, fat free sour cream, 1 tbsp of natural peanut butter, etc.
i. Recommended: at least 64 oz of liquids, 60-80 grams of protein eaten before rest of meal, 3
servings of fruits and vegetables (add these in one at a time to diet to determine what you
can and cannot tolerate), 3 servings of whole grains DAILY
ii. Supplements: daily multivitamin with iron added (must be chewable and 200% of DV),
calcium with vit. D (1200-1500mg, also chewable), B12 sublingually (1000 mcg), and D3
chewable (1000 IU). All must be taken daily.
g. (Tufts Medical Center, Guide for eating after gastric bypass surgery - tufts medical center)

19. Identify the steps you would take to monitor Mr. McKinley’s nutritional status postoperatively. (livi)
At every post-op appointment I would like a lipid profile to be taken of Mr. McKinley to see his LDL,
HDL, cholesterol, and triglycerides, I would also like to monitor his potassium levels. Abnormal potassium
levels could contribute to cardiac arrest. I would also ask for a urine sample before each post-op
appointment so I could determine his hydration status by specific gravity and urine osmolality. I would ask
that a food diary be taken every day throughout the first six months monitoring how he responds to
different foods and additions into his diet. And to ensure that he is drinking between meals not with.
Another step I would take is consistent glucose and HA1C tests to monitor the diabetes mellitus. I would
like to look at his skin to see the integrity of the skin that had rashes between the folds. I would calculate
his BMI at every appointment, but more importantly I would take a weight measurement to determine how
much weight loss was occurring. And lastly I would keep an eye out for symptoms that are consistent with
dumping syndrome, like nausea, vomiting, diarrhea, bloating, cramping, etc.
(SA;, Assessing hydration status) (NCBI, Medical Management of the postoperative bariatric ... - NCBI
bookshelf)

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22. Write an ADIME note for your inpatient nutrition assessment with initial education for the Stage 1 and
2 (liquid) diet for Mr. McKinley.(Hanna)
ADIME note
Nutritional Assessment:
Age/Gender: 37 years old/Male
Nutritionally relevant PMH: type 2 diabetes mellitus, hyperlipidemia, hypertension, and
osteoarthritis
Admitting Dx: class 3 obesity(high-risk)

Current Nutrition Order: preoperative nutrition education program

Diet History: unknown

Food Allergies/Intolerances: NKA
Interval History: since beginning the preoperative nutrition education program pt has lost 24 lbs
GI:

Nutrition-focused physical findings:

HEENT:WNL
Neck:WNL
Heart:WNL
Lungs:Clear to auscultation
Abdomen:Obese, soft, some epigastric tenderness BS 4
Overall Appearance/NFPE: obese white male
Skin Integrity: pale, warm, good skin turgor, ecchymosis, abrasions, rash, mucus membranes intact.
Nutrition-related LDA: N/A

Anthropometrics:
Weight History: Mr. McKinley has weighed over 250 lbs since age 15 with steady weight gain since
that time. He has attempted to lose 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, but since the beginning
of the preoperative nutrition education program he has lost 24 lbs.
UBW: 94%
Admission weight/source: 434/class 3 obesity
Height:5’10
BMI and classification: 58.7 ->class 3 high risk extreme obesity

Nutritionally relevant labs: high potassium, high glucose, high CPK, high cholesterol, low HDL-C,
high VLDL, high LDL, high LDL/HDL, high HbA1c

Nutrition-related medications: Metformin 1000 mg/twice daily; 35 u Lantus pm; Lasix 25 mg/day;
Lovastatin 60 mg/day

Estimated nutritional needs: avoid eating too much food while still consuming the necessary
nutrients, mainly protein, all while eating small meals in order to not have dumping syndrome to occur.

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 Avoiding high sugar beverages and foods, drinking anywhere from 20-48 oz of clear liquids, eating high
protein foods, and avoiding overeating.

Calories: 1500 - 1875 k/cal per day for weight loss post surgery

Protein: 75-97 g protein/day

60 - 75 g of protein/ day

Fluid: at least 64 oz of fluids

Weight used to assess needs:

Nutrition diagnosis(PES #1): Excessive energy intake is related to type 2 diabetes, hyperlipidemia,
hypertension, and osteoarthritis as evidenced by class 3 obesity.

Nutrition recommendations/interventions:
1. Follow post–bariatric-surgery diet
2. Provision of the iron supplements, elemental calcium, vitamin D, multivitamin supplements
after surgery
3. He works as an office manager, that is he is following a sedentary lifestyle. Sedentary
lifestyle increases chances of weight become higher
4. After surgery, he is prohibited from exercise until 12 weeks after surgery. He can walk after
surgery. Walking can be advised for him 20 minutes per day and gradually increased over
6-8 weeks. After 6-8 months after surgery, he began show weight loss

Nutrition Monitoring and evaluation:

-following steps to be taken to identify his dietary pattern after post opertively. in the first 24 hours
after surgery, he should be consume water and sugar free liquid [Link] that he can be provided with high
protein liquid diet for 2 weeks and after 2 weeks to 4 week, he can be provided with a pureed diet. he is
monitored for any bleeding problems due to iron deficiency, poor wound healing due to deficiency of
calcium. monitor his intake and output and daily weight monitoring helps to identify nutritional status

Goal: Patient maintains post-op diet and schedule for postoperative visit in one week.

Follow-up day:7 days

(Shipley, ADIME, 2022)
Additional Questions
1. What other healthcare professionals may be involved in this patient’s care? What are their roles?
Consider both inpatient and outpatient encounters. (livi)
a. Inpatient:
i. Bariatric lead surgeon, assisting surgeon, scrub nurse, theater assistants. The anesthetic team
consists of anesthesiologists and CRNAs (anesthesiologist's assistant).

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 1. All involved with the actual surgery and post-op check ins while still in hospital, and
potentially seeing the surgeon outpatient to check on scars and the effectiveness of
the surgery for Mr. McKinley.
b. Outpatient/post-op:
i. Bariatric nurse specialists endocrinologists, gastroenterologists, dieticians and nutritionists,
doctors, nurses, pharmacists, health care assistants, and administrative staff.
1. Some would be needed for post operative while still in hospital. Most of these
professionals would be needed after leaving the hospital and necessary to monitor
changes in his weight/size/BMI.
c. (NCBI, Roux-en-Y gastric bypass - statpearls - NCBI bookshelf)
2. Discuss in 5 sentences or less, the impact of healthcare policy and different healthcare delivery
systems on this patient’s care. resource:[Link]
(Hanna)

Research continues to show that nutrition intervention can drastically improve one's health and reduce the risk for
many chronic diseases related to obesity. Nutrition counseling that promotes lifestyle changes to include healthier
diets and more physical activity have the potential to reduce type 2 diabetes by 34%. Nutrition counseling by a
registered dietitian nutritionist can make a world of a difference for chronic disease management, treatment, and
prevention.

(Franklin, 2017)

Work Cited

Alila Medical Media. (2014, August 08). Roux en-Y gastric bypass, with introduction on Body mass index,

animation. Retrieved September 30, 2022, from

[Link]

Alila Medical Media. (2014, August 08). Gastric sleeve and lap band surgeries for weight loss treatment,

animation. Retrieved September 30, 2022, from

[Link]

dex=24

Franklin, M. (2017, December 19). Prevention and health care reform. Retrieved September 30, 2022, from

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 [Link]

NCBI. (n.d.). Medical Management of the postoperative bariatric ... - NCBI bookshelf. Retrieved September 30,

2022, from [Link]

NCBI. (n.d.). Roux-en-Y gastric bypass - statpearls - NCBI bookshelf. Retrieved September 30, 2022, from

[Link]

Quercia, I., Dutia, R., Kotler, D., Belsley, S., & Laferrère, B. (2014, April). Gastrointestinal changes after bariatric

surgery. Retrieved September 30, 2022, from [Link]

SA;, K. (n.d.). Assessing hydration status. Retrieved September 30, 2022, from

[Link]

20and,estimate%20of%20hydration%20is%20necessary.

Shipley, Jessica (2022). Powerpoint slides from in class, posted on iLearn.

Shipley, Jessica (2022). ADIME sample and ADIME note template. Posted on iLearn.

Tufts Medical Center. (n.d.). Guide for eating after gastric bypass surgery - tufts medical center. Retrieved

September 30, 2022, from

[Link]

%20and%20Services/Weight%20and%20Wellness%20Center/GBP%20Diet%[Link]

UCSD. (n.d.). Dietary Guidelines After Weight-Loss Surgery. Retrieved September 30, 2022, from

[Link]

UCSF Health. (2022, June 24). Bariatric Surgery Requirements and Evaluation. Retrieved September 30, 2022,

From

[Link]

eligible%20for%20weight,pressure%20or%20severe%20sleep%20apnea.

Weir, C., & Jan, A. (2022, June 27). BMI classification percentile and cut off points - statpearls - NCBI …

Retrieved September 30, 2022, from [Link]

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