Medical Nutrition Therapy: A Case-Study Approach , 5th Edition Solution Manual

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Answer Guide forMedical Nutrition Therapy: A Case Study Approach5thed.Case 1–Pediatric Weight ManagementI.Understanding the Disease and Pathophysiology1.Current research indicates that the cause of childhood obesity ismultifactorial. Briefly outline howgenetics,environment, and nutritional intake might contribute to the development of obesity in children.Biological (genetics and pathophysiology):•30%-75% of adiposity in children is related to genetics•In children < 3 years of age, the strongest predictor of adulthood obesity is parental obesity•Both prenatal undernutrition and overnutrition appear to increase lifelong risk for obesity•Genetic/hormonal: Some of the most common are:oPrader-Willi syndromeoCushing’s syndromeoHypo-/hyperthyroidismEnvironmental (sedentary behaviors, SES, modernization, culture, dietary intake):•Video and computer games and cable and satellite television have made sedentary activities more appealingo98% of children inthe U.S. live in homes with at least one televisiono80% of children live in homes with at least one DVD playeroHalf of the children who live in the U.S. have at least one video game system in their homesoOn average, children spend 3 hours per daywatching television•African American and Hispanic children participate in fewer vigorous activities and/or more sedentaryactivities than Whites•Girls are less physically active than boys•Dietary factorsoLow intake of vegetables and fruitsoHigh intake of fast foods and sweetsoIncreased consumption of sugar-sweetened soft drinksoSkipping breakfastoIncreased consumption of refined carbohydrates (ready-to-eat cereals, potatoes, cakes, biscuits, softdrinks)oIncreased parental work hours influence (leads to higher consumption of energy-dense foods)oConsumption of all 3 meals leads to 63% lower risk of being overweight/obeseMother smoking during pregnancy; increased risk of being overweightExtensive food marketing towards children (via video games,internet, TV, cell phones, etc.)Global (society, community, organization, interpersonal, individual):•Community design focused on cars has discouraged walking and bike riding•Increased concerns about safety limit timesand areas in which children play outside•Time in physical education classes in schools has decreased•Limited number of parks and recreation areas in communities2.Describe one health consequence for obese children affecting each of the following physiological systems:cardiovascular, orthopedic, pulmonary, gastrointestinal, and endocrine.•OrthopedicoAbnormalities affecting feet, legs, hipsoSlipped capital femoral epiphysisoBlount’s disease (bowing of lower legs & tibial tortion)•NeurologicaloPseudotumor cerebri (increased pressure in skull)oRecurrent headaches•PulmonaryoAsthma

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oSleep disordersoSleep apnea•GastrointestinaloCholecystitisoHepatic steatosisoGallstones•EndocrineoType 2 DMoPolycystic ovary syndrome (PCOS)oHirsutismoAcneoAcanthosis nigricansoEarly puberty & menarche•PsychologicaloLow self-esteemoDepressionoPeer rejection•CardiovascularoHypertensionoHyperlipidemia3.How does Jamey's current weight status affect her risk ofdeveloping adulthood obesity?4.Jamey has been diagnosed with obstructive sleep apnea. What isobstructive sleep apnea? Explain therelationship between sleep apnea and obesity.•Sleep apnea literally means “sleep without breath.”•It is diagnosedin individuals who experienceperiods (at least 10 seconds) of not breathing for a variety ofreasons.•In the case of Jamey, obstructive sleep apnea is caused bythecollapse of soft tissue in the throat, whicheffectively blocksher air passage.•Strong correlations existbetween weight and occurrence of sleep apnea, especially with the size of aperson’s neck and visceral fat.•Larger neck sizes putastrain ontheairway, and visceral fat puts pressure on the lungs, decreasing lungfunction (although the function is not decreased during waking periods at rest).•Additionally, Jamey may have tonsillar hypertrophy (another factor to consider with sleep apnea).II.Understanding the Nutrition Therapy5.In general, what are the goals for weightloss in the pediatric population? Are there concerns to considerwhen developing recommendations for an overweight child who is still growing?•Since children are still growing in height, weight-loss goals should be realistic and should not necessarilyattempt to fully normalize weight.•For children at risk for overweight with no identified complications,maintenance of current weight isrecommended. Prolonged maintenance will allow a gradual decline in BMI units as children grow inheight.•For children who are overweight and those overweight with complications, gradual weight loss isrecommended.•Rate of weight loss should be based on health risks and recommended with caution. Primary goals oftreatment are:oPromote healthful lifestyle behaviors to achieve and maintain a desirable body weightoWell-balanced diet that supports growth and developmentoBehavior modificationoIncreased physical activity

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oFamily involvementoImprove/resolve complications of obesity if presentIn children, generally weight loss should not exceed 2 lbs per week and this high rate of weight loss isgenerally reserved for the 6-11 yr olds in the 99th %-tile or 12-18 yr olds with ≥ 95%-tile6.List four recommendations that might serve as goals for thenutritional treatment ofJamey’s obesity?•Involve the entire family and/or all caregivers.•Encourage family activities that provide everyone with exercise.•Low-fat, low-cholesterol,reduced-sugar diet per age, weight, or BMI and nutritional requirements.Make healthy eating fun by using bright colors and unique kid-friendly conceptsoex.: ants on a log, incorporate child in meal prep, etc.•Encourage planned meals, especially breakfast. Discourage skipping meals.•Discourage eating while watchingtelevision.•Avoid use of food as a reward or punishment.•Stock refrigerator with healthy food and drink choices.•Familyshouldeat meals together as often as possible.•Learn to read food labels for healthier food selections.•Select appropriate portion sizes at home and when eating out.•Reduce number of meals eaten outside the home.•Encourage 30-60 minutes of moderate physical activity most days of the week.•Promote a variety of exercises to prevent boredom or overtraining.oafter school activities, active video gamesIII.Nutrition Assessment7.AssessJamey’s weight using the CDC growth charts provided(p. 8): What is Jamey’s BMI percentile? Howis her weight status classified? Use the growth chart to determine Jamey’s optimal weight forher height andage.•BMI: 24.9, percentile: >95th.•Jamey would be classified asobese. The CDC and others regard this childto bein the highest weightclassification for age.•The approximate optimal weight for Jamey’s age is 70-72 lbs and her approximate optimal height for age is55 in.8.Identify two methods for determining Jamey’s energy requirements other than indirect calorimetry, and thenuse them to calculate Jamey’s energy requirements. What calorie goals would you use to facilitate weightloss?•Total Energy Expenditure, or TEE1(for weight maintenance in overweight ages 3-18 years):oTEE = 389–(41.2age[y]) + PA(15weight [kg] + 701.6height [m])Where PA is the physical activity factor:PA = 1.00 ifphysicalactivity level (PAL)sedentaryPA = 1.18 if PAL low activePA = 1.35 if PAL activePA = 1.6 if PAL very activeoTEE = 389–41.2(10) + 1[15(52.3 kg) + 701.6(1.45 m)]oTEE = 389–412 + 785 + 1017oTEE = 1779 orround to1800 kcal/day for ease1National Academy of Sciences Food and Nutrition Board.Dietary Reference Intakes for Energy, Carbohydrate,Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, D.C.: The National Academies Press,2005.

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•kcal/cmo12-15 kcal/cm for very low energy needs (sedentary)o12 × 145 = 1740 kcalo15 × 145 = 2175 kcalFor weight loss deduct 108 kcal/day (= 1lb wt)9.Dietary factors associated with increased risk of overweight are increased dietary fat intake andincreasedcalorie-dense beverages. Identify foods from Jamey’s diet recall that fit these criteria.•Whole milk•Apple juice•Coffee with cream and sugar•Mayonnaise•Fritos® corn chips•Bologna & cheese sandwich•Twinkies®•Peanut butter•Fried chicken•Fried okra•Mashed potatoes with whole milk and butter•Sweet tea•Coca-Cola®10.Calculate the percent of kcal from each macronutrient and the percent of kcal provided by fluids for Jamey’s24-hour recall.•Total kcal:~ 4419;44% fat, 42% CHO, and 14% protein•Fluid kcal:~ 957; 22% of kcal11.Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey’sdiet fall into these categories?Apple juice, fried okra, and potatoes are the only fruit and vegetables sheconsumed.12.Use the ChooseMyPlate online tool (available from www.choosemyplate.gov; click on “Daily Food Plans”under “SuperTracker and Other Tools”) to generate a customized daily food plan. Using this eating pattern,plan a 1-day menu for Jamey.Example (answers will vary):oAM: 1 c frosted shredded wheat with 4-8 oz skim milk, 1 c orange juice, and whole-wheat bagel (can use atbsp of cream cheese or butter if desired). Drink at least 8 oz of water.oLunch: PB&Jsandwich (use whole-wheat bread), 15 wheat thins (or 21 small pretzels), 8 oz skim milk.oAfter-school snack: Turkey sub (2 or 3 slices of deli turkey, spinach, and 1 tbsp low-fatRanch on hoagie orpreferably whole-wheat bread), 8 oz skim milk. Drink at least 8 oz water.oDinner: Beef burrito (2 oz ground beef, 1 oz refried beans, 1 oz salsa, 1 oz cheddar cheese), dress withtomato, lettuce, onion, corn. 20 oz water (or 12 oz juice).oSnack: Banana, orange, or any other fresh fruit you like.13.Now enter and assess the 1-day menu you planned for Jamey using the MyPlate SuperTracker online tool(http://www.choosemyplate.gov/supertracker-tools/supertracker.html). Does your menu meet macro-andmicronutrient recommendations for Jamey?Answers will vary according tothe answer to #12.14.Why did Dr. Lambert order a lipid profile and blood glucose tests?What lipid and glucose levels areconsidered altered (i.e., outside of normal limits) for the pediatric population?EvaluateJamey’s lab results.

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•The combination of being overweight, nightly urination, HTN, and increased appetite along with a familyhistory of gestational diabetes are cluesthatthere may be an increased risk for diabetes.•Weight status, HTN, and family history are all risk factors for CVD, so performing a lipid panel helps toscreen for additional risk factors that can be controlled early on.•Altered lab results:*Total Cholesterol>170 mg/dLLDL Cholesterol>110 mg/dLHDL Cholesterol≤35 mg/dLTriglycerides≥150 mg/dLGlucose60-100 mg/dL•Cholesterol and triglycerides areWNL.•LDL and HDL levels are close to being outside oftheacceptable range.•The glucose levelisjust outside normal range,but she just ate breakfast two hours before she came in. Tobe sure, a fasting glucose would be prudent.*Using this text laboratory values as reference. Substantial variation exists in the ranges quoted as “normal”and these may vary depending on the assay used by different laboratories.IV.Nutrition Diagnosis15.Select two nutrition problems and complete PES statements for each.Following are possible PES statements. It may be helpful for students to initially write more than two nutritiondiagnoses and then prioritize as to the ones most likely to have immediate nutrition interventions.Clinical:•Overweight related to physical inactivity and excessive energy intake as evidenced by BMI of 24.9 (>95%)Intake:•Excessive energy intake related to snacks and meals consisting of calorically dense foods and beveragessuch as whole milk, regular sweetened sodas, and fried foods as evidenced by typical daily caloric intake ofapproximately 4400 kcal compared to recommended daily intake of 1800-2000 kcal(Students could also write a similar PES using "Excessive oral food/beverage intake" as theproblem.)Behavioral/Environmental:•Physical inactivity related to overweight, fatigue,and limited PA at school as evidenced by usual activitieslimited to playing video games and reading•Undesirable food choices related to knowledge deficit and low intake of fruits and vegetables as evidencedby frequent intake of juices, whole milk, sweetened beverages, refined carbohydrates, fried foods, andhigh-fat meals•Food-and nutrition-relatedknowledge deficit as evidenced by Jamey’s mother inquiring about the use offood rewards to motivate an increase in physical activity andexercise (in this case an etiology may not benecessary)V.Nutrition Intervention16.What behaviors associated with increased risk of overweight would you look for when assessing Jamey’s andher family’s diets?What aspects of Jamey’s lifestyle place her at increased risk for overweight?Behaviors to look for:•Sedentary lifestyle•Snacks•Family’s dinner-time ritual: TV trays or together at the dinner table?•Parents’ knowledge about benefits of fruits, vegetables, whole grains, and physical activity should beassessed.Parents restriction of highly desired food (may lead to overeating when food is available)

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Meals away from home/fast-food/restaurant frequency•It may help to explain that she feels tired because of the sleep apnea. Once that is treated and she begins aregular schedule of physical activity she may want to be more active.Being sedentary is the biggest. She also seems to habitually snack while doing nothing.17.You talk with Jamey and her parents, who are friendly and cooperative. Jamey’s mother asks if it would helpfor them to not let Jamey snack between meals and to reward her with dessert when she exercises. Whatwould you tellthe family regarding snacks between meals and rewards with dessert after exercise?•Snacks between meals are acceptable as long as they are healthy snacks.oFruits and vegetables would be ideal.oFoods with mix of protein, carbs, fat, and fiber may help prolong satietyoPortion control for snacking•Instead of using dessert as a reward,Jamey’smother should offer to do some kind of activity like going tothe park or shopping withher—anything that will encourage physical activity.18.Identify one specific physical activityrecommendation for Jamey.•If it’s nice out, Jamey and her mother could go out for a walk in the evenings.•Ininclement weather, Jamey and her mother could play the latest motion video game.Find organized physical activity/sport for Jamey (social/accountability aspect may enhance interest)19.For each PES statement written, establish an ideal goal (based on signs and symptoms) and an appropriateintervention (based on etiology).Clinical:•Overweight related to physical inactivity andexcessive energy intake as evidenced by BMI of 24.9Ideal Goal:BMI within normal range and less than 85thpercentileIntervention:Nutrition counseling with focus on behavioral modification (refer to specific interventionsassociated with the intake and behavioral problems defined below).Intake:•Excessive energy intake(or oral food/beverage intake)related to snacks and meals consisting of caloricallydense foods and beverages such as whole milk, regular sweetened sodas, and fried foods as evidenced bytypical daily caloric intake of approximately 4400 kcal compared to recommended daily intake of 1800-2000 kcalIdeal Goal:Average daily kcal intake within recommended range of 1800-2000 kcalIntervention:Nutrition education to develop alternative foods and beverages that are nutrient dense.Modify distribution, type,and amount of foods within meals and snacks to include:•Reduced-fat milk•Water for thirst instead of sweetened colas•Decreased portion sizes•Increase of fruits, vegetables, and whole grainsBehavioral/Environmental:•Physical inactivity related to overweight, fatigue and limited PA at school as evidenced by usual activitieslimited to playing video games and readingIdeal Goal:Increase in physical activity (can specify an amount or type if desired)Interventions:In this case, interventions may not necessarily be directed at the etiologies as defined but bedesigned to lessen signs and symptoms; therefore, nutrition counseling would use the strategies of goalsetting,rewards and reinforcement (not foods), and social support to promote physical activities that are

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realistic and appropriate for both Jamey and her parents. Students should include in their answer the needfor exploring a variety of options that are fun and non-competitive.•Undesirable food choices related to knowledge deficit and low intake of fruits and vegetables as evidencedby frequent intake of juices, whole milk, sweetened beverages, refined carbohydrates, fried foods, andhigh-fat meals.Ideal Goal:Even though this PES statement is quite similar to the intake example noted above, the goalswould be defined slightly differently. Instead of a specific caloric goal, goals for this PES would be basedon the amount and type of foods described in the signs and symptoms, such as “no more than 4 oz of fruitjuice daily” or “limit fried foods to one time weekly,” etc.Intervention:A similar intervention as notedin the intake sectionabove is appropriate as well.•Food-and nutrition-relatedknowledge deficit as evidenced by Jamey's mother inquiring about the use offood rewards to motivate an increase in physical activity and exerciseIdeal Goal:Jamey’s mother providing appropriate non-food rewards to motivate an increase in physicalactivityIntervention:Nutrition education stating the purpose and use of family counseling theory and strategiesthat include problem solving, social support, and goal setting.20.Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey.Based on the Evidence Analysis Libraryfrom the Academy of Nutrition and Dietetics, what are the recommendations regarding gastric bypasssurgery for the pediatric population?TheExpert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child andAdolescent Overweight and Obesity2include the following criteria for adolescents being considered for weight-loss surgery:•Failure of at least six months of organized weight-loss attempts as determined by their primary careprovider•Severely obese (BMI 40 or greater) with serious obesity-related medical complications or have a BMI of 50or more with less-severe co-morbidities•Co-morbidities related to obesity that might be resolved with durable weight loss•Attainment of a majority of skeletal maturity (generally at least 13 years of age for girls and at least 15years of age for boys).•Demonstrate commitment to comprehensive medical and psychological evaluations both before and afterweight-loss surgery•Capable and willing to adhere to nutritional guidelines post-operatively•Able to decide and participate in the decision to undergo weight-loss surgery.•Have a supportive family environment•Evaluated by a multi-disciplinary team involved in patient selection, preparation,and surgery as well asimmediate and long-term post-operative follow-up carePotential candidates should be referred to centers with multi-disciplinary weight-management teams that haveexpertise in meeting the unique needs of obese adolescents. Surgery should be performed in institutionsequipped to meet the tertiary needs of severely obese patientsthatcollect long-term data on the clinicaloutcomes of these patients.VI.Nutrition Monitoring and Evaluation2Sarah E. Barlow and the Expert Committee. Expert Committee Recommendations Regarding the Prevention,Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report.Pediatrics,2007;120;S164-S192. (P. S185).

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21.What is the optimal length of weight management therapy for Jamey?•Nutrition counseling should includegoal-setting, self-monitoring, stimulus control, problem-solving,contingency management, cognitive restricting, use of incentives and rewards, and social supports•MNT should last at least 3 months or until initial weight-management goals are achieved•Weight control is often a life-long condition and it is critical that a weight management plan beimplemented after the intensive phase of treatment•More contact betweenthepatient and RD may lead to more successful weight loss and maintenance22.Should her parents be included? Why or why not?•Family counseling is very important and improves weight management outcomes.Degree of counseling format depends on the family dynamics and should be determined by theprofessional's discretion (ex.: group vs. individual, caregiver and child vs. parent, etc.)•Parents need to be ready to make lifestyle changes to support the child/adolescent with cognitive behaviorstrategies.Parental modeling has advantages in children under 12 years of age•Components include:onutrition education on lifestyle behaviors and their relationship to chronic disease developmentomodification ofthehome/school environment to enable the adolescent to make wise food choicesoself-monitoring and motivation to change bymodeling behaviors and contracting23.What would you assess during a follow-up counseling session? When should this occur?•Accurate measurement of height and weight, plottedon CDC Growth Chart•24-hour recall with either FFQ or food record•Identify areas that have been changed and can be changed•Patient’s and parents’ motivation to change•Physical activity record/recallotype of physical activity adolescent participates inotype of physical activity parents participate inotime spent watching TV, video games, or on computer•Real or perceived limitations•Body image•Ethnic or religious practices and beliefs related to food•Use of vitamins, supplements, and alcohol or drugs by patientLab values (lipid profile/glycemic control) if availableWeekly visits/follow-ups lasting 8-12 weeks lead to the most effective outcomes. (Once every 2-3 weeksmay be more realistic)

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Answer Guide forMedical Nutrition Therapy: A Case Study Approach4thed.Case 2–Bariatric Surgery for Morbid ObesityI.Understanding the Disease and Pathophysiology1.Define the BMI and percent body fat criteria forthe classification of morbid obesity.What BMI is associatedwith morbid obesity?•Body mass index (BMI) is usually used as a common method for determining if someone is obese since itis easy and quick.BMI>30 is considered obese.•Obesity can be defined as a fat percentage greater than≥25% fat inmalesand≥33% infemales. However,this requires tools and skill so BMI is more commonly used even though BMI does not factor in bodycomposition.The National Institutes of Health do not recognize percent body fat as criteria for morbidobesity.•BMI≥40 is considered morbidly obese for both men and womenBMI ≥ 35 plus one or more comorbid condition100 lbs or more over IBW•For children, obesity is defined using the CDC growth charts that provide BMI for age data.≥the 95thpercentileor≥30 kg/m2(whichever represents the lower weight)isconsidered an obese classification.•TheDietary Guidelines for Americanshave different classifications for obesity. Class 1 is a BMIof30-34.9;class 2, aBMIof35-39.9;and extreme obesity (class 3),a BMI≥40 kg/m2.•Waist circumference can be used to determine mild obesity but it is a poor indicator of morbid obesity.Awaist circumference >40in. men or>35in. in women indicates obesityor increased risk for CVD. This isbased on the fact that central adiposityis thought topropose a higher risk for CVD than gynoid obesity.2.List 10health risks involved with untreated morbid obesity. What health risks does Mr. McKinley presentwith?Risks with untreated morbid obesity include:•Type 2 diabetes: 3asprevalent among obese persons compared to those with normalweight•Hypertension (high blood pressure):3more common in the obese•Dyslipidemia (abnormal lipid profile, high cholesterol, low HDL, high LDL, high triglycerides)•Gallstones: 6greaterrisk for gallstones among persons who are obese•Non-alcoholic fatty liver disease: central adiposity is a risk factor for NAFLD•Cancer:•Men are at an increased risk for esophageal, colon, rectum, pancreatic, liver, and prostate cancers•Women are at an increased risk for gallbladder, bile duct, breast, endometrial, cervix, and ovariancancers.•Coronary heart disease•Myocardial infarctions (heart attacks)•Angina (chest pain)•Sudden cardiac death•Sleep apnea (inability to breathe while sleeping or lying down)•Asthma•Reproductive disorders:•Men: gynecomastia (enlarged mammary glands in males), hypgonadism, reduced testosterone levels,and elevated estrogen levels•Women: menstrual abnormalities, polycystic ovarian syndrome•Metabolic syndrome•Premature death: obese individuals have a 50-100% increased risk of premature death compared to healthy-weight individuals.•Bone health: obesity can increase chances of osteoporosis or decreased bone mineral densityHealth risks Mr. McKinley presents with:•Osteoarthritis

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•Type 2 diabetes•Hyperlipidemia•HypertensionMetabolic Syndrome (TG ≥ 150 mg/dL, HDL < 40 mg/dL, BP ≥ 130/85 mmHg; also highly likely that hisFPG ≥ 100 mg/dL due to DM dx)•Mr. McKinley has been obese his whole life, which puts him at an increased risk for type 2 diabetes,hyperlipidemia, hypertension, 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.•The patient should be morbidly obesewith a BMI ≥40 or...•...The patient should be obese with a BMI≥35 and display a co-morbidity such as cardiovascular disease,sleep apnea, or diabetes.•Surgery isan optionwhen the patient has failed to lose weight by other,less invasive meansor if the co-morbidities pose a significant health risk.•However,many bariatric protocolsrequire that a patient lose some weight prior to the operation todemonstrate thathe or she iswilling to followthrough with lifestyle changes relating to exercise and diet.•Mr. McKinleyis a candidate for surgery because he is morbidly obese with a BMI of 59 (BMI >40) and hehas several co-morbidities including: type 2 diabetes, hypertension, and hyperlipidemia.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 thepersonnel involved in the evaluation and care of the patient in this particular program.Internet search information is taken from:http://www.obesityhelp.com/forums/vsg/about_vertical_sleeve_gastrectomy.htmlQualification information: for low-BMI individuals that should consider this procedure:•Those concerned by long-term complications of intestinal bypass•Those who are concerned about a lap-band, or inserting a foreign object into the abdomen•Those who have other medical problems that prevent them from having weight-loss surgery such asanemia, Crohn’s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and othercomplex medical conditions•People who need to take anti-inflammatory medications;VSGpresentsa lower riskfor developmentofulcers after taking anti-inflammatory meds after surgeryPersonnel involved:•Laparoscopic Associates of San Francisco (LAPSF)•Obesityhelp.com•“In more than 700 patients, there were no deaths, no conversions to open and a leak rate of less than 1%.”(obesityhelp.com)•Study showed that two-year weight-loss results from the vertical gastrectomy were similar to the roux-en-Y.•57% weight loss using the vertical gastrectomy compared to41% forthe lap-band procedure.•This case is associated with a team of several doctors from LAPSF.5.Describe the following surgical procedures used for bariatric surgery including advantages, disadvantages,and potential complications.a.Roux-en-Y gastric bypassDescription:•Most common restrictive-malabsorptive procedure.•A small pouch is created at the top of the stomach, which restricts food intake by increasing satiety.The jejunum is cut at the distal end and is attached to the small pouch at the top of the stomach, whichbypassesthe rest of the stomach, the duodenum, and the first part of the jejunum in order to restrictdigestion and absorption.

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•The proximal end of the jejunum that is draining the stomach is surgically connected to the lower endof the jejunum, allowing for secretions from the liver, gallbladder and the pancreas to enter thejejunum to aid in digestion and absorption.Advantages:•Weight loss is achieved through this procedure by decreasing food intake, increasing satiety,anddeceasing absorption.•Dramatic improvements in diabetes, sleep apnea, hypertension, cancer,and cardiovascular disease risk.•Potential 40% reduction in mortality.•laparoscopic procedure, which is minimally invasive.Disadvantages:•Vitamin and mineral deficiencies;may need lifelong supplementation.•Cannot take NSAIDs after surgery.•Emotional and physical stamina are needed to be willing to make the necessary dietary and lifestylechanges.•Nutrient deficiencies are more common because it is a restrictive-malabsorptive procedure, especiallyforfat-soluble vitamins (A,D,E,K),vitamin B12, folate, iron,andcalcium.oThe stomach is being bypassed, whichresults in loss ofintrinsic factor, which is necessary for B12absorption.oThe stomach provides acidity for iron absorption, which may be impairedfollowingthisprocedure.Potential complications:•Development of gallstones, anemia, metabolic bone disease, osteoporosis•Ulcers if patient smokes after surgery•Nausea/vomiting if too much food is consumed•Dumping syndrome (diarrhea, nausea, flushing, bloating from decreased transit time and from eatingrefined carbohydrates)b.Vertical sleeve gastrectomyDescription:•Up to 85% of the stomach is removed but leaves the pylorus intact and preservesthe stomach’sfunction.•There is a tubular portion of the stomach between the esophagus and the duodenum, restrictingremaining stomach’s holding capacity to 50-150mL.•The surgeon places two rows of staples through both walls of the stomach and then cuts through bothwalls of the stomach between the lines of the staples, separating the stomach into two sections.•Procedure causes a decrease in food intake by restricting the stomach’s capacity and is considered arestrictive procedure.Advantages:•Minimal nutrient malabsorption.•Removing part of the stomach results in a loss of the hormone ghrelin, which further enhances weightloss because ghrelin plays a role in hunger.•Dumping syndrome is usually avoided by leaving the pylorus intact.•Effective for weight loss in high-BMI candidates.•Laparoscopic, which is minimally invasive.Disadvantages:•Weight regain is more possible because it does not involve intestinal bypass. Instead, it relies on adecrease in food intake.•Procedure is not reversible.•High-BMI candidates will most likely need a second procedure to aid in further weight loss. VSG actsas a beginning surgery.Potential complications:Leaks related to the stapling procedure may occur.

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c.Adjustable gastric banding (Lap-Band®)Description:•Silicone ring or band is laparoscopically introduced into the abdominal cavity and secured around theupper part of the stomach to create a small pouch with a narrow opening at the bottom of the pouchthrough which food passes into the rest of the stomach.•The band restricts the stomach’s capacity to as little as 30mL.•As time goes on, the band can be adjusted to increase the capacity of the stomach.•The band is inflated with saline, which narrows the opening at the bottom of the pouch. This delaysgastric emptying, allowing the patient to feel full longer.•Most common restrictive procedure.Advantages:•Complications are least likely to result from AGB compared to other bariatric procedures.•Hospital stay and post-op recovery are shorter thanforthe other procedures.•Band can be adjusted to suit patient’s caloric needs.•Simple and the least invasive of the procedures.Potentially reversible, though challenging in clinical practiceDisadvantages:Patients lose weight at a slower rate thanafterrestrictive-malabsorptive procedures such asthe roux-en-Y gastric bypass procedure.Potential complications:Risk of tear in the stomach during the operation; potential for nausea, vomiting,heartburn, and abdominal pain. The band may slip, which would require additional surgery.d.Vertical banded gastroplastyDescription:Upper portion of stomach is stapled with a one-centimeter hole at the bottom of the pouch thatallows for a very slow passage of food into the lower portion of the stomach. This procedure restrictsoverall oral intake due tothe stomach’sdecreasedcapacity, aiding in weight loss.Advantages:•Simple, non-invasive.•Procedure is reversible.•Does not change the normal digestive pathways.Disadvantages:•Weight regain is possible because it does not involve intestinal bypassand the pouch may stretch overtime. Instead, it relies on a decrease in food intake•Breaking of staples.•Nausea and vomiting if excessive amounts of food are consumed.•May have difficulty digesting high-fiber foods.Potential complications:Possible complications associated with surgery, infection,etc.e.Duodenal switchDescription:•Portion of stomach removed to reduce stomach’s capacity and thus food intake.•Pyloric valve stays intact to maintain normal digestion of nutrients.•The intestinal pathway is re-routed to separate the flow of food from the flow of bile and pancreaticjuices to inhibit absorption ofenergy-yielding nutrients.•The pathways are then re-joined before the large intestine, bypassing a lot of the absorption in thesmall intestine.Advantages:•Keeping the pyloricvalveintact reduces the risk for dumping syndrome.

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•Significant weight reduction.Disadvantages:•More aggressive procedure, which means more complications associated with the procedure.•Heavydietary restrictions.Potential complications:•Leaks•Blood clots•Bowel obstruction•Abscesses•Kidney failure•Bleeding•Pneumonia•Infection•Osteoporosis•Anemia•Deficienciesofvitamin A, calcium, vitamin D, and proteinf.Biliopancreatic diversionDescription:•Often performed with a duodenal switch•Restrictive-malabsorptive procedure•Least frequently performed•Laparoscopically performed vertical sleeve gastrectomy•Bypass of food through the intestine, resulting in more weight loss•Distal part of the small intestine is surgically attached to the stomach•Secretions from the liver, gallbladder, and pancreas are re-routed so they can eventually enter the smallintestine to aid in digestion and absorption.Advantages:Greatest amount of weight reductionDisadvantages:Usually only performed on patients with BMI >50Potential complications:See complications for duodenal switch6.Mr. McKinley has had type 2 diabetes for several years. His physician shared with him that after surgery hewill not be on any medications for his diabetes and that he may be able to stop his medications for diabetesaltogether. 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?•Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) stimulate insulinsecretion. GLP-1 also suppresses glucagon and slows gastric emptying, which delays digestion and reducespostprandial glycemia. GLP-1 also acts on the hypothalamus to induce satiety. Bariatric surgery increasesthe levels of these hormonesand are hypothesized to dramatically improve glycemic control post-operatively.•Weightloss will improve insulin sensitivity and contribute to improved glycemic control.•Bariatric surgery restricts food intake to a small portion of food at each sitting, which increases satiety andhelps prevent hyperglycemia.•Other conditions that may be affected by weight lossincludecardiovascular disease. If hyperglycemia canbe controlled, it may reduce the damage to the blood vessels,which aids in reducing risk of cardiovasculardisease.•Sleep apnea will be improved with weight reduction,as there isless mass around the respiratory muscles.•Hyperlipidemia can be improved. As the patient eats more consistently with a decreased capacity, lipidprofiles may begin to normalize as the patient loses weight.•Blood pressure can be lowered with weight reduction, aiding inresolvinghypertension.May reduce risk of cancer as obesity is linked with some forms of cancers

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May improve psychological health as obesity is associated with feelings of guilt, depression, anxiety, andlow self-worthII.Understanding the Nutrition Therapy7.How does the Roux-en-Y procedure affect digestion and absorption? Do other surgical procedures discussedin question #5 have similar effects?Significant section of stomach bypassed, reducing gastric acid needed for promoting the ferrous state ofiron (needed for absorption) and reduced intrinsic factor for B12 absorptionAdditionally, gastric acid is needed to cleave many minerals and vitamins from other molecular structuresand promote their absorbable formsDuodenum and proximal jejunum bypassed, thus reducing the overall surface area and time for digestionand absorptionLactose intolerance may transiently occur due to the production of lactase in the removed part of the smallintestine; adaptation can occurDeficiencies infat-soluble vitamins (A,D,E,K),vitamin B12, folate, iron,andcalciumare commonOther surgical procedures like the duodenal switch and biliopancreatic diversion may have similar effectsdue to their alterations in the GI tract pathways/release of digestive enzymes8.On post-op day one, Mr. McKinley was advanced to the Stage 1 Bariatric Surgery Diet. This consists ofsugar-free clear liquids, broth, and sugar-free Jell-O. Why are sugar-free foods used?•Sugar-free foods are used to prevent dumping syndrome.•Dumping syndrome ischaracterized bynausea, vomiting, bloating, and diarrhea and is caused byhyperosmolar foods, which are usually simple carbohydrates.•The hyperosmolar foods cause water to be pulled into the intestine. This occurs because part of the intestineis bypassedand the pyloric sphincter is removedin the roux-en-Y procedure, which gives less surface areaand transit time for absorption.•In order to prevent dumping syndrome, theANDNutritionCareManualrecommendsavoiding simplecarbohydrates such as fruit juices or other foods high in sugar.9.Over the next two months, Mr. McKinley will be progressed to a pureed-consistency diet with 6-8 smallmeals. Describe the major goals of this diet for the Roux-en-Y patient. How might the nutrition guidelinesdiffer if Mr. McKinley had undergone a Lap-Band procedure?•Since roux-en-Y is a restrictive-malabsorptive procedure, it is important to consume very small meals,usually 2-4 Tbspat one time,to decrease the risks of dumping syndrome. 6-8 small meals are neededbecause the stomach has a very limited capacity.•Other major goals of the diet include:oProtein-dense foods (at least 60 g of protein per day);protein helps with the healing process aftersurgery and it helps with satiety sothepatient can recognize thathe/she isfull before eating too much.Protein should be consumed first at the meal.oAvoid high-sugar beverages and foods.Liquids should be consumed between meals to avoid dumpingsyndrome(wait 30 min. after a meal).Meet a fluid goal of 48 to 60 oz (or more) per day. Initially,during the stage 1 and stage 2 diets, the recommendation is to consume at least 24 to 30 oz of clearliquids and at least 24 to 30 oz of full liquids; however, once the diet transitions to soft foods, theindividual can continue consuming full liquids if he or she chooses but should consume at least 48 to60 oz of clear liquids daily.If Mr. McKinley had a lap-band procedure,his risk forvitamin and mineral deficiencieswould be lowerbecause a lap-band procedure is restrictive but not a restrictive-malabsorptive procedure. A lap-bandprocedure simply reduces the size of the stomachwithoutbypassingintestinal absorption.Dumpingsyndrome is not as significant of a concern; patients eased into larger-sized meals due to small pouchreservoir created within the stomach.In addition, the lap-band procedure is adjustable, so food intake can be suited to meet the patient’s needs.

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10.Mr. McKinley’s RD has discussed the importance of hydration, protein intake, and intakes of vitamins andminerals, especially calcium, iron, and B12. For each of these nutrients, describe whya deficiency may occurand explain the potential complications that could result from deficiency.•Calcium:Sincemost of the stomach is bypassed, there isareduction in thegastric acidity that aids incalcium absorption, causing potential deficiencies andrisk of osteoporosis.Additionally, calcium salts canform due to the malabsorption of fatty acids.•Iron:Iron is mostly absorbed in the duodenum of the small intestine. It also needs the acidity from thestomach, which is mostly bypassed in the roux-en-Y procedure,to aid in absorption. Therefore, iron maybe malabsorbed and an iron deficiency may occur. Iron deficiency may lead to iron-deficiency anemia.•B12:B12is absorbed in the ileum, but it requires intrinsic factor, which is released from the stomach. Thestomach is mostly out of commission, so the absorption of B12is affected.B12deficiency may lead topernicious anemia and a folate deficiency.•Protein:Since the stomach’s capacity is very limited,thepatient must restrict their food intake to about 2-4Tbspper meal. Protein should be taken first to help with satiety and to aid in healing after surgery. In case aperson cannot tolerate the whole meal, it is important for protein-dense foods to be consumed so the persondoes not break down lean body mass when losing weight. Protein malnutrition may also lead to furtheredema and other micronutrient deficiencies.•Hydration:Hydration is key but liquid should be consumed between meals to minimize dumpingsyndrome. Hydration goes hand in hand with protein intake. With risk of dumping syndrome, excess watercould be lost from diarrhea, so it is important to stay adequately hydrated to prevent dehydration. Inaddition, as one loses weight, water weight will be lost,making hydration very important.III.Nutrition Assessment11.Assess Mr. McKinley’s height and weight. Calculate his BMI and % usual body weight. What would be areasonable weight goal for Mr. McKinley? Give your rationale for the method you used to determine thisgoal weight.•BMI=703410lbs/70in./70in.= 59•% UBW=(410lbs/434lbs)100= 95% UBW•A reasonable weight goal would be to lose 30-35% of body weight within 1-2 years post-op.0.3410= 123lbs, 410-123lbs= 287lbs.0.35410= 143.5lbs.,410-143.5= 266.5 lbs.Therefore, since research shows that most patients lose about 30-35% of their weight, it would bereasonable for Mr. McKinley to lose between 123 and144lbs.within the firsttwo years.•Studiesdemonstratethat 60% of patients typically maintain weight once weight is lostpost-surgery.•Another goal would be to get Mr.McKinley’sBMI below 30,sinceevidence shows a significant reductionin the risk for co-morbidities associated with obesity when BMI is less than 30.This is equivalent to a goalweight <209 lbs.12.After reading the physician’s history and physical, identify any signs or symptoms that are most likely aconsequence of Mr. McKinley’s morbid obesity.•Elevated blood pressure (135/90mmHg): more strain on the blood vessels due to obesity•Pitting edema•Skin rash (impaired blood flow to the skin due to obesity)•Elevated respiration rate: hard to breathe with excess weightcompressinglungs and other respiratorymusclesDiminished pulses may be due to excessive subcutaneous fat absorbing forceof heart beat/observed pulse

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