Bariatric Surgery- Case Study #2Connie Bisesi and Taryn Berry

I. Understanding the Diagnosis and Pathophysiology1. Discuss the classification of morbid obesity.

Morbid obesity is classified when a patient's BMI is above 40 kg/m^2. Waist to hip ratio may also be used and can assess if the patient is at risk for developing metabolic syndrome. A waist circumference under 1.0 cm for men and 0.8 cm for women is suggested. There are more than 30 co morbidities associated with morbid obesity. Insulin resistance and diabetes occur in 15%-25% of obese patients. These patients may also experience the following: an increase amount of abdominal fat which leads to gastroesophageal reflux from intra-abdominal pressure, stress urinary incontinence, venous stasis disease, abdominal hernia, nonalcoholic steatohepatitis, and joint and back stress. Thorough medical history, physical examination, and focused testing, will uncover most co morbidities in two thirds of obese patients.

o Source : Obesity. (n.d.). Retrieved October 7, 2014, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/obesity

2. Describe the primary health risks involved with untreated morbid obesity. What health risks does Mr. McKinley present with?

Untreated morbid obesity can lead to numerous different health risks such as cardiovascular disease, hypertension, diabetes mellitus, high cholesterol, respiratory problems, gastroesophageal reflux, urinary stress incontinence, cancer, skin infections, degenerative arthritis and infertility. Morbidly obese patients are at a higher risk for abnormal lipid panels, and hormone levels. Obesity increases cholesterol levels therefore increasing risk for cardiovascular diseases, which then increases the risk for a myocardial infarction. Due to Mr. McKinley’s untreated morbid obesity, he is diagnosed with type 2 diabetes mellitus, hypertension, hyperlipidemia, and osteoarthritis. His cholesterol, VLDL, LDL and LDL/HDL ratio are increased as his HDL is decreased which are all related to untreated morbid obesity.

o Source : Health Risks of Morbid Obesity | NYULMC Weight Management Program | NYU Langone Medical Center | New York, NY. (n.d.). Retrieved October 2, 2014, from http://thinforlife.med.nyu.edu/surgical-weight-loss/obesity/health-risks-morbid-obesity

3. What are the standard adult criteria for consideration as a candidate for a bariatric surgery? After reading Mr. McKinley’s medical record, determine the criteria that allow him to qualify for surgery.

In order to be considered as a candidate for bariatric surgery, a patient must be classified as morbidly obese relating to a BMI above 40 kg/m^2, as well as a failed attempt to lose weight through non-surgical measures. A patient may also be considered for bariatric surgery if they are classified as obese relating to a BMI above 35 kg/m^2 and have a health condition putting them at high-risk for other diseases. Such diseases include cardiovascular disease or diabetes mellitus. Mr. McKinley would be considered a candidate for bariatric surgery because he is diagnosed with type 2 diabetes mellitus, hypertension and is classified as morbidly obese with a BMI of 58.8 kg/m^2.

o Source : Welcome to Cleveland Clinic. (n.d.). Retrieved October 3, 2014, from https://weightloss.clevelandclinic.org/AmIaCandidate.aspx

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 Bariatric Surgery program at Yale-New Haven Hospitals defines morbid obesity as a person who has a BMI greater than 40 or 35 if the patient has diabetes, high blood pressure, or obstructive sleep apnea. If the person has a BMI at or above these values, they may be a candidate for bariatric surgery. Next, the person must fill out a “weight-loss surgery candidate form,” which consists of personal information, service of interest, how you heard of their program, insurance, and if the person wants to attend a seminar, webinar, or phone call. An in-person seminar or webinar is a necessary first step to the weight loss surgery process. Next, the patient will see the doctor, nutritionist, and mental health professional to evaluate nutrition knowledge and commitment to change. The surgeon will evaluate which surgery will work best with consideration to body size and configuration, previous surgeries, and other health problems. After surgery, there are follow-ups scheduled 2 weeks, 2 months, 6 months, and 12 months after the surgery. There are also free bariatric support groups that meet monthly at New Haven. A nutritionist, mental health professional, bariatric surgeon(s), and a primary care physician are involved in the care and evaluation of the patient.

o Source : Bariatric Surgery Program. (n.d.). Retrieved October 1, 2014, from http://www.ynhh.org/bariatric-surgery/

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

a. Roux-en-Y gastric bypass (RYGB)-this is the most accepted and commonly performed restrictive-malabsorptive procedure in North America. RYGB creates a small (20-30 mL) pouch at the top of the stomach to restrict food intake and inducing satiety quicker. Food bypasses the rest of the stomach, the duodenum, and the first part of the jejunum, which reduces food digestion and nutrient absorption.

The jejunum is cut and the distal end, roux limb, is surgically connected to the pouch. This makes contents bypass part of the small intestine. Also, the proximal end of the jejunum is connected to the lower segment of the jejunum. This allows secretions from the stomach, liver, gallbladder, and pancreas to eventually enter the jejunum and mix with the contents leaving the pouch. RYGB is usually done laparoscopically.b. Vertical sleeve gastrectomy (VSG)-up to 85% of the stomach is surgically removed, leaving a narrow, tubular, banana shaped portion of the stomach, called the gastric sleeve, between the esophagus and the duodenum. This restricts the stomachs holding capacity to 50-150 mL.This procedure preserves function, leaves the pylorus intact, which allows for nearly no malabsorption. VSG is done laparoscopically by putting two rows of staples through the stomach walls. This divides the stomach into two halves, removing the side that is not attached to the esophagus and duodenum. There may be lower serum levels of ghrelin after this procedure because the part of the stomach that is removed is primarily responsible for producing this hormone.c. Adjustable gastric banding (Lap-Band or AGB)-an inflatable silicone ring or band is laparoscopically put in the abdomen and secured around the top of the stomach to create a pouch with a narrow opening, or stoma, at the bottom so that food can pass through the rest of the stomach. This limits the amount of food that can be consumed at one time. The pouch originally has a capacity of 30 mL but can potentially stretch to 90 mL. The band is connected to a port by a tube under the skin in the abdomen. When saline is injected into the port, the band inflates and the stoma becomes narrowed. This delays the emptying of the pouch, which creates a greater sense of fullness. This is the most commonly performed restrictive procedure because it does not require any stapling or cutting of the stomach, so hospitalization and postoperative recovery time is shorter. Lastly, this procedure is reversible and patients lose weight slower but the end results are about the same as the other procedures.d. Vertical banded gastroplasty (VBG)-adjustable gastric banding has replaced vertical banded gastroplasty so it is rarely used anymore. This is when the top of the stomach is stapled vertically to create a pouch along the inner curve of the stomach. The outlet from the pouch to the rest of the stomach is restricted by a band, restricting food from emptying. This creates the feeling of being full. This procedure does not cause any problems with absorption or digestion.e. Duodenal switch-this is the second stage of the biliopancreatic diversion. This procedure re-routes food from the stomach past the small intestine, the duodenum and jejunum. The ileum is surgically attached to the stomach and secretions from the liver, gallbladder, and pancreas are rerouted, through a biliopancreatic limb, allowing them to eventually enter the small intestine.f. Biliopancreatic diversion-this procedure has two parts. The first is the vertical sleeve gastrectomy so that the patient has some weight loss and reduced risk

factors in order to get the second procedure. The second procedure is a duodenal switch. This is the most complicated procedure but has the best results with the most weight loss. Because of its complexity, it is reserved for very obese patients with a BMI greater than 50.0 kg/m^2 that have surgery complication due to obesity or other conditions linked to obesity.o Source : Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.).

Belmont, CA: Wadsworth, Cengage Learning.o Source : Vertical banded gastroplasty: MedlinePlus Medical Encyclopedia

Image. (n.d.). Retrieved October 5, 2014, from http://www.nlm.nih.gov/medlineplus/ency/imagepages/19498.htm

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 medication 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 bariatric surgery, there is a major possibility type 2 diabetes will go into remission. The surgery can help improve type 2 diabetes once at a normal weight. Weeks after surgery, about 90% of patients with type 2 diabetes come back with normal blood sugar levels. As blood sugars begin to return to reference ranges, diabetes cannot continue to progress, therefore sending the condition into remission. Because blood sugars and hemoglobin values normalize, there isn’t a need for diabetes medications or insulin injections. No other medical treatment achieves such effects in morbidly obese patients. Many other medical conditions can be affected by weight loss such as hypertension, high cholesterol, heart disease, stress urinary incontinence, and gastroesophageal reflux disease. Roughly 70% of patients with hypertension who undergo bariatric surgery, can stop taking blood pressure meds while 80% of patients’ cholesterol levels normalize within a couple months. Relief of gastroesophageal reflux disease symptoms resolve almost immediately and stress urinary incontinence, because of weight loss, responds positively to the surgery.

o Source : (n.d.). Retrieved October 6, 2014, from https://weightloss.clevelandclinic.org/images/file/Benefits and results of bariatric surgery.pdf

II. Understanding the Nutrition Therapy7. 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? Added sugars may lead to Dumping Syndrome, so for prevention measures, sugar-

free foods will be used. Dumping syndrome causes the food to exit the body at a rapid rate resulting in diarrhea, vomiting, nausea, and dizziness. Sugary foods are also high in calories contributing to weight gain.

o Source : Post-Surgery FAQs, MUSC Bariatric Surgery Program, Charleston SC. (n.d.). Retrieved October 3, 2014, from http://www.muschealth.com/weightlosssurgery/resources/faq.htm

8. 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?

o The reason why there is a progression over two month to pureed-consistency foods is to protect the surgery lines where staples were put and to avoid food getting caught or blocking an opening when healing. If Mr. McKinley had undergone a Lap-Band procedure, the step to eating a pureed-consistency diet is much faster because there was no cutting or stapling of the stomach. Eating smaller meals and limiting the amount of refined carbohydrates is more important to avoid nausea, vomiting, or dumping syndrome.

9. 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 intake may be inadequate and explain the potential complications that could result from deficiency?

Hydration-hydration may be inadequate because of vomiting and diarrhea if dumping syndrome takes place after eating. The recommendation is to drink 6-8 cups of water throughout the day to stay hydrated. It is also recommended to wait 30-60 minutes after eating food to drink fluids and to not drink and eat at the same time. This will avoid having a slick gut, hyperosmolality, and hyperglycemia, which leads to dumping syndrome. All liquids should be counts into the 6-8 cups. Water, sugar-free, non-alcoholic, non-caffeinated, non-carbonated beverages are suggested.

Protein-Protein is imperative for the healing of wounds, muscle mass, production of hormones and enzymes, blood clotting, blood pressure, and immune health. High quality, low fat protein is needed first at every meal in order to maintain all the functions stated above.

Calcium-Calcium is important to maintain strong bones and carrying out different functions of cells. Patients should take 1000 mg of calcium vis supplement split two times daily. After about 2 months, tablets can be used but should not be taken with iron due to reaction. Lactose is often not tolerated by patients postoperative so dumping syndrome may take place. This would diminish calcium absorption in the body. This is why a supplement is recommended till the whole food stages.

Iron-Iron is very important in the process of oxygen transport all throughout the body. It keeps the body from forming blood disorders, such as anemia.

B12-B12 is found in animal meat sources which may not be able to be consumed. This is required for proper red blood cell formation, neurological function, and DNA analysis.

o Source : Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.

III. Nutrition Assessment10. 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 our rationale for the method you used to determine this.o Mr. McKinley was admitted at 410 lbs at a height of 5’10”. With this height and

weight, he has a BMI of 58.8 kg/m^2 with a classification of morbidly obese. Mr. McKinley has a usual body weight of 434 pounds but was admitted at 410 pounds; therefore he is currently at 94.48% of his usual body weight. Using the Hamwi method, Mr. McKinley’s ideal weight should be between 149.4 lbs and 182.6 lbs. Because Mr. McKinley has been overweight since a young age, we can assume that he is most likely a large frame individual so his ideal weight is most likely closer to 182.6 pounds. With that being said, if Mr. McKinley were to reach his weight goal of 182.6 pounds, it would be a 251.4-pound loss, or 61.3% of his body weight. ○ BMI Calculation:

■ 410 lb/ 2.2 = 184.6 kg■ 70 inches x .00254 m = 1.778 m■ 184.6/ (1.778)^2 = 58.8 kg/m^2

○ % UBW Calculation■ Body Weight= 184.6 kg■ Usual Body Weight 434lb/2.2 = 197.3 kg■ (186.4/ 197.3) x 100 = 94.48%

○ Hamwi Method■ 106 lb + (10 inches x 6 lbs) =166lbs■ 166 lbs x 1.10 = 182.6 lbs■ 166 lbs x .90 = 149.4 lbs

11. 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. After reading Mr. McKinley’s history and physical assessment, his type 2 diabetes

mellitus, hypertension, hyperlipidemia and osteoarthritis are most likely a consequence of his morbid obesity. All four conditions are noted on his medical history, and are prime consequences from a classification of morbid obesity. Other than his medical history, his surgical history shows a consequence of Mr. McKinley’s weight. 3 years prior, Mr. McKinley had a right total knee replacement most likely because of the extra weight he held on his knee joints. He also presents with a rash under his abdominal skin folds, a consequence from extra abdominal fat.

12. Identify any abnormal biochemical indices and discuss the probable underlying etiology. How might they change after weight loss? The following table shows all the abnormal biochemical indices:

●

Chemistry Ref. Range 2/23

Potassium (mEq/L) 3.5-5.5 5.8

Glucose (mg/dL) 70-110 145

CPK (U/L) 55-170 M 220

Cholesterol (mg/dL) 120-199 320

HDL-C (mg/dL) >45 M 32

VLDL (mg/dL) 7-32 45

LDL (mg/dL) <130 232

LDL/HDL ratio < 3.55 7.5

Triglycerides (mg/dL) 40-160 M 245

HbA1c (%) 3.9-5.2 7.2

● Mr. McKinley’s lab values show a high level of cholesterol, VLDL, LDL and LDL/HDL ratio. Each is associated with his hyperlipidemia due to morbid obesity, and puts him at risk for heart disease. McKinley also showed a high level of triglycerides indicating diabetes mellitus as well as a high blood glucose level. His high CPK values indicate hypothyroidism, which is when the thyroid doesn’t produce proper amounts of hormones. With an increased HbA1c value, this tells us that his type 2 diabetes mellitus is putting him at risk for complications such as kidney disease or stroke. After bariatric surgery, Mr. McKinley will possibly see a decrease in triglyceride levels, blood glucose levels, and cholesterol levels. His type 2 diabetes mellitus will most likely go into remission, which will reduce the glucose levels and HbA1c levels after a few months.

○ Source: A1c test: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved October 1, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm

13. Determine Mr. McKinley’s energy and protein requirements to promote weight loss. Explain the rationale for the method you used to calculate these requirements. To maintain his weight, Mr. McKinley should consume 3,879 calories a day. To

promote a weight loss of one pound per week, he should consume roughly 3,379 calories a day. Because of the bariatric surgery, he might have trouble consuming that high of calories, so to promote a weight loss of two pounds per week he should consume roughly 2,879 calories a day. This plan would be after two months of surgery. Immediately after surgery, daily caloric intake should not exceed 1000 calories. If he is choosing to lose one pound per week, he should be consuming

between 85 and 269 grams of protein or 10-35% of his daily calories. If he is choosing to lose two pounds per week, he should be consuming between 72 and 252 grams of protein, or 10-35% of his daily calories.

○ Total Energy Expenditure Calculation■ 66+ (13.7 x 184.6 kg) + (5 x 177.8 cm) - (6.8 x 37 ) = 3,234. 42

calories■ 3,324.42 calories x 1.2 (PA) = 3, 878.904 calories

○ Protein Calculation■ One pound per week: 3,379 calories x .10 = 337.9 calories or 84.5

grams■ One pound per week: 3,379 calories x .35 = 1,182.65 calories or 295.6

grams■ Two pounds per week: 2,879 calories x .10 = 287.9 calories or 72

grams■ Two pounds per week: 2,978 calories x .35 = 1,007.65 calories or

251.9 grams The previous calculations show Mr. McKinley losing weight from a progression of

where he currently was pre-surgery. Because he just had Bariatric surgery, for the first two weeks he should be consuming about 400 calories but absolutely no more than 1000 calories per day, and about 15 grams of protein. From two weeks to eight weeks he should be consuming about 500 calories a day but absolutely no more than 1000 calories and about 19 grams of protein. From two to six months he should be consuming about 1000 calories a day and 38 grams of protein. From six months on nutritional intake would be individualized per patient.

IV. Nutrition Diagnosis14. Identify at least two pertinent nutrition problems and the corresponding nutrition

diagnoses.● Excessive Oral Intake (NI-2.2) related to high consumption of foods as evidenced by

BMI of 58.8 kg/m^2 and weight of 410 lbs. ● Excessive Fat Intake (NI-5.6.2) related to consumption of fatty foods as evidenced

by a cholesterol level of 320 mg/dL and LDL levels of 232 mg/dL. ● Physical Inactivity (NN-2.1) related to sedentary lifestyle as evidenced by a BMI of

58.8 kg/m^2 and weight of 410 lbs.

V. Nutrition Intervention15. Determine the appropriate progression of Mr. McKinley’s post-bariatric-surgery diet.

Include recommendations for any supplementation that you would advise.● After Bariatric surgery, there are five nutrition phases one will go through to fully

recover. Each meal will take about 20-30 minutes to eat and no more than ½ cup should be consumed at one time. Meals should be high in protein, and low in fat and sugar. Phase 1 happens during hospital stay and involves only clear liquids such as

crystal light, clear broth, sugar free jello, and water. Phase 2 begins two to three days after surgery, and lasts about two weeks. It involves full (non-clear) liquids such as skim milk, hot cocoa, or a protein shake. About 400 calories should be consumed during this phase. Phase 3 begins two weeks after surgery and lasts till about five weeks. It includes pureed foods such as blended cottage cheese, and blended fruit. About 500 calories should be consumed during this phase. Phase 4 begins at five weeks and lasts till about eight weeks. It includes soft and easy to digest foods such as scrambled egg whites, applesauce a and baked potato. About 500 calories should be consumed during this phase. Phase 5 begins at week eight and includes all regular foods. About 1000 calories should be consumed during this phase. For all phases, it is recommended that at minimum, fluid intake is 64 oz a day. Supplementation is key during nutrition recovery after Bariatric surgery. Multivitamins should be taken twice a day for about three months, 1,200-2000 mg of calcium should be taken daily, 800-1,000 IU of vitamin D should be taken daily, and 500 mcg of Vitamin B12 should be consumed daily.

● Source : Dietary Guidelines After Bariatric Surgery. (n.d.). Retrieved October 5, 2014, from http://www.ucsfhealth.org/education/dietary_guidelines_after_gastric_bypass/

16. Describe any pertinent lifestyle changes that you would view as a priority for Mr. McKinley. There are many pertinent lifestyle changes that we view as a priority for Mr.

McKinley. This would include a change in diet, and increased physical activity. Taking in less calories, and eating more nutrient dense foods will aid him in weight loss, and controlling complications related to morbid obesity such as hypertension. Alcohol should be limited, and nutrition education/counseling should be done so Mr. McKinley is aware of what foods will inhibit weight loss.

17. How would you assess Mr. McKinley’s readiness for a physical activity plan? How does exercise assist in weight loss after bariatric surgery? Because Mr. McKinley has led a sedentary lifestyle for the majority of his 37 years,

we want to slowly introduce him to low-vigorous activities, such as walking. Bariatric surgery will lead to a lower weight but doesn’t necessarily promote a healthier lifestyle (physical activity). Bariatric surgery promotes weight loss, and helps subside weight related issues, which in turn can make physical activity easier or less painful on the joints. We would assess Mr. McKinley’s readiness for physical activity in nutrition counseling, measuring his own confidence in starting a plan. When he is ready, we would demonstrate certain activities so he knows exactly how to complete the task.

VI. Nutrition Monitoring and Evaluation

18. Identify the steps you would take to monitor Mr. McKinley’s nutritional status postoperatively. Postoperatively, we plan to reassess Mr. McKinley’s lab values daily until he is

discharged from the hospital. From there, his lab values will be monitored once a month to ensure his values are normal. Other than biochemical assessment, we plan to assess Mr. McKinley’s food intake and physical activity through a food diary and exercise diary. He will record what he ate, when he ate and the amount as well as the duration, type and intensity of exercise on a daily basis. These dairies will be discussed, and suggestions will be made on bi-monthly nutritional counseling basis.

19. From the literature, what is the success rate of bariatric surgery? What patient characteristics may increase the likelihood of success? Bariatric surgery has very impressive results making it the most effective weight loss

therapy for patients with clinically defined severe obesity. Most patients lose within 30-35% of their body weight within 1-2 years after surgery. With effective maintenance, 10 years after surgery, there is weight loss of about 60% body weight. There are also significant improvements in diabetes, sleep apnea, hypertension, and CVD risk factors. Success is considered when 50% of body weight has been lost after surgery and it is maintained for 5 years.

Factors that help increase the likelihood of success are patients that follow the nutrition intervention postoperative. Having commitment to change their lifestyle in the areas of nutrition and exercise is very important to attaining long term success from bariatric surgery. This includes primarily avoiding added sugars and fatty foods, and incorporating an exercise programs. It is also easier if they have a support group that can help them stay motivated to maintain their weight loss and goals.

o Source : Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.

20. 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?

Bariatric surgery in children is extremely controversial as no studies have been done to document the long term effects on the child’s future growth and development. In order for a child to be considered for weight loss surgery they should: be morbidly obese with a BMI of greater than 40 kg/m^2 with weight related complications or a BMI greater than 50 kg/m^2 with less complications, have attained physiological or skeletal maturity, and have failed with six or more months of weight management. Bariatric surgery should not be considered in adolescents if there is a medically correctable cause of obesity, substance abuse, or pregnancy within two years of the surgery.

o Source : Adolescent Bariatric Surgery :: The Cleveland Clinic. (n.d.). Retrieved October 8, 2014, from https://weightloss.clevelandclinic.org/bsurgeryadolesandteen.aspx

21. Write an ADIME not for your inpatient nutrition assessment with initial education for the Stage 1(liquid) diet for Mr. McKinley.● Assessment:

○ 37 year old man admitted for Roux-en-Y gastric bypass surgery on 2/24. Height of 5’10” and weight of 410 lbs, with a BMI of 58.8 kg/m^2. Classified as morbidly obese, he has a UBW of 434 lbs, and has been obese the majority of his life. He has type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis and received a right total knee replacement 3 years ago. Family history of type 2 diabetes mellitus, CAD, hypertension, COPD, and osteoporosis. Currently taking Metformin 1000 mg/twice daily, 35 u Lantus at night, Lasix 25 mg/day and Lovastatin 60 mg per day. Lives a sedentary lifestyle, casually drinking 2-3 beers per week. Normal temperature, and pulse with high respiration rate of 23, and blood pressure of 135/90. Normal physical assessment except for edema, petechiae on lower extremities, ecchymosis, and rash under abdominal skinfolds. High potassium glucose, CPK, cholesterol, VLDL, LDL, LDL/HDL ratio, triglycerides and HbA1c% values.

● Diagnosis:○ Excessive Oral Intake (NI-2.2) related to high consumption of foods as

evidenced by BMI of 58.8 kg/m^2 and weight of 410 lbs. ○ Excessive Fat Intake (NI-5.6.2) related to consumption of fatty foods as

evidenced by a cholesterol level of 320 mg/dL and LDL levels of 232 mg/dL. ○ Physical Inactivity (NN-2.1) related to sedentary lifestyle as evidenced by a

BMI of 58.8 kg/m^2 and weight of 410 lbs. ● Intervention:

○ Postoperatively, he will receive nutrition counseling and education daily until he is discharged from the hospital. Immediately after surgery for the first three days, he will proceed to a nutrition phase 1, or clear liquid diet. He will consume 400 calories of a mixture of the following: sugar free jello, water, clear broth, sugar-free popsicles, crystal light, sugar free beverages or decaffeinated tea/coffee. Once he is discharged, he will continue on with phase 2-5, and incorporate walking 4 times a week, 20 minutes each time. He will consume 64 ounces of fluid daily, and eat a high-protein, low sugar, low fat diet no matter what phase of the recovery process.

● Monitoring and Evaluation:○ Postoperatively, we plan to reassess Mr. McKinley’s lab values daily until he

is discharged from the hospital. After he is discharged, his lab values will be monitored once a month to ensure all values are within reference range. Other than lab assessment, we plan to assess Mr. McKinley’s food intake and physical activity through a food diary and exercise diary. In the food diary, he will record what he ate, when he ate and the amount. In his exercise diary, he will record the duration, type and intensity of exercise on a daily basis. These

dairies will be discussed, and suggestions will be made on bi-monthly nutritional counseling basis. During nutrition counseling, weight will be measured and BMI will be calculated. As a result of changing measurements, meal plans, and exercise plans will change on a daily basis.

References

A1c test: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved October 1, 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm

Adolescent Bariatric Surgery :: The Cleveland Clinic. (n.d.). Retrieved October 8, 2014, from https://weightloss.clevelandclinic.org/bsurgeryadolesandteen.aspx

Bariatric Surgery Program. (n.d.). Retrieved October 1, 2014, from http://www.ynhh.org/bariatric-surgery/

Dietary Guidelines After Bariatric Surgery. (n.d.). Retrieved October 5, 2014, from http://www.ucsfhealth.org/education/dietary_guidelines_after_gastric_bypass/

Health Risks of Morbid Obesity | NYULMC Weight Management Program | NYU Langone Medical Center | New York, NY. (n.d.). Retrieved October 2, 2014, from http://thinforlife.med.nyu.edu/surgical-weight-loss/obesity/health-risks-morbid-obesity

(n.d.). Retrieved October 6, 2014, from https://weightloss.clevelandclinic.org/images/file/Benefits and results of bariatric surgery.pdf

Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth, Cengage Learning.

Obesity. (n.d.). Retrieved October 7, 2014, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/obe

sity

Post-Surgery FAQs, MUSC Bariatric Surgery Program, Charleston SC. (n.d.). Retrieved October 3, 2014, from http://www.muschealth.com/weightlosssurgery/resources/faq.htm

Welcome to Cleveland Clinic. (n.d.). Retrieved October 3, 2014, from https://weightloss.clevelandclinic.org/AmIaCandidate.aspx

Vertical banded gastroplasty: MedlinePlus Medical Encyclopedia Image. (n.d.). Retrieved October 5, 2014, from http://www.nlm.nih.gov/medlineplus/ency/imagepages/19498.htm

Nutrition Plan for PPT: http://www.nationwidechildrens.org/bariatric-surgery-nutrition http://www.mayoclinic.org/tests-procedures/bariatric-surgery/in-depth/gastric-bypass-diet/art-20048472

Nutrition Guidelines for PPT: http://www.ucsfhealth.org/education/dietary_guidelines_after_gastric_bypass/

low fat and sugar foods, high proteinfluid intake 64 oz