Solution Manual For Medical Nutrition Therapy: A Case Study Approach, 4th Edition

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1-1Answer Guide forMedical Nutrition Therapy: A Case Study Approach4thed.Case 1–Pediatric Weight ManagementI.Understanding the Disease and Pathophysiology1.Current research indicates the cause of childhood obesity is multifactorial. Briefly outline the roles ofgenetics, environment, and nutritional intake in 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 in the 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 day watching 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)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 health consequences of overweight and obesity for children.•OrthopedicoAbnormalities affecting feet, legs, hipsoSlipped capital femoral epiphysisoBlount’s disease (bowing of lower legs & tibial tortion)•NeurologicaloPseudotumor cerebri (increased pressure in skull)oRecurrent headaches•PulmonaryoAsthmaoSleep disordersoSleep apnea•GastrointestinaloCholecystitisoHepatic steatosis

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1-2oGallstones•EndocrineoType 2 DMoPolycystic ovary syndrome (PCOS)oHirsutismoAcneoAcanthosis nigricansoEarly puberty & menarche•PsychologicaloLow self-esteemoDepressionoPeer rejection•CardiovascularoHypertensionoHyperlipidemia3.Jamey has been diagnosed with obstructive sleep apnea. Definesleep apnea.•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.4.Explain the relationship between sleep apnea and obesity.•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.What are the goals for weight loss in the pediatric population?•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 activityoFamily involvementoImprove/resolve complications of obesity if present6.Under what circumstances might weight loss in overweight children not be appropriate?•Pregnancy•HIV/AIDS

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1-3•Oncology treatment•Severe psychiatric disorders•Metabolic diseases such as Prader-Willi syndrome7.What would you recommend as the current focus for nutritional 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.•Encourage planned meals, especially breakfast. Discourage skipping meals.•Discourage eating while watching television.•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.III.Nutrition Assessment8.Evaluate Jamey’s weight using the CDC growth charts provided: What is Jamey’s BMI percentile? How isher weight status classified?Use the growth chart to determine Jamey’s optimal weight and height for age.•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.9.Identify two methods for determining Jamey’s energy requirements other than indirect calorimetry, and thenuse them to calculate Jamey’s energy requirements.•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 ifphysical activity 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 ease•kcal/cmo12-15 kcal/cm for very low energy needs (sedentary)o12 × 145 = 1740 kcalo15 × 145 = 2175 kcal1National 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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1-410.Dietary factors associated with increased risk of overweight are increased dietary fat intake and increasedcalorie-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®11.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 kcal12.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.13.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&J sandwich (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.14.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 #13.15.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.•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.

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1-5•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 are fine.•LDLand HDL levels are dangerously 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.16.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.•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 tell them?•Snacks between meals are acceptable as long as they are healthy snacks.oFruits and vegetables would be ideal.•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 activity recommendation 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.IV.Nutrition Diagnosis19.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.)

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1-6Behavioral/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 knowledge deficit as evidenced by Jamey’s mother inquiring about the use of foodrewards to motivate an increase in physical activity and exercise (in this case an etiology may not benecessary)V.Nutrition Intervention20.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 and excessive 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 arerealistic 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 noted above is appropriate as well.

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1-7•Food and nutrition knowledge deficit as evidenced by Jamey's mother inquiring about the use of foodrewards 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.21.Mr. and Mrs. Whitmer ask about using over-the-counter diet aids, specifically Alli (orlistat). What would youtell them?No pharmacological agents for weight loss have been approved for use in children under the age of 12.22.Mr. and Mrs. Whitmer ask about gastric bypass surgery for Jamey.Using the EAL, what are therecommendations regarding gastric bypass surgery 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 Evaluation23.What is the optimal length of weight management therapy for Jamey?•Nutrition counseling should include goal-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 maintenance24.Should her parents be included? Why or why not?2Sarah 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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1-8•Family counseling is very important and improves weight management outcomes.•Parents need to be ready to make lifestyle changes to support the child/adolescent with cognitive behaviorstrategies.•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 by modeling behaviors and contracting25.What would you assess during this follow-up counseling session?•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

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2-1Answer Guide forMedical Nutrition Therapy: A Case Study Approach4thed.Case 2–Bariatric Surgery for Morbid ObesityI.Understanding the Disease and Pathophysiology1.Discuss the classification of 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 in females and >33% in males. However,this requires tools and skill so BMI is more commonly used even though BMI does not factor in bodycomposition.•BMI>40 is considered morbidly obese for both men and women.•For children, obesity is defined using the CDC growth charts that provide BMI for age data.≥the 95thpercentile is considered 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 canbe 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.Describe the primary health risks involved with untreated morbid obesity. What health risks does Mr.McKinley present with?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•Type 2 diabetes•Hyperlipidemia•Hypertension

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2-2•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 is a resort used when the patient has failed to lose weight by other,less invasive means.•However, often times, physicians require 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.•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.

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2-3Advantages:•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.•The section attached to the esophagus and duodenum is removed.•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 further down the road to aid in furtherweight loss. VSG acts as a beginning surgery.Potential complications:Leaks related to the stapling procedure may occur.c.Adjustable gastric banding (Lap-Band®)

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2-4Description:•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.Disadvantages: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-centimer 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.•Significant weight reduction.Disadvantages:•More aggressive procedure, which means more complications associated with the procedure.•Heavydietary restrictions.

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2-5Potential 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?•Weight reduction is part of the management of diabetes because it aids in gaining blood glucose control.•Bariatric surgery restricts food intake to a small portion of food at each sitting, which increases satiety andhelps prevent hyperglycemia.•The controlled food intake helps with keeping blood glucose levels from becoming too high.•Weight reduction alsoreducesinsulin resistance. Receptors become more sensitive to insulinwhenanindividual is in a more normal weight range. The chronic inflammatory stateassociated with obesityhinders glucose uptake into the cells.•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.II.Understanding the Nutrition Therapy7.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.

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2-6•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 bypassed in the roux-en-Y procedure, which gives less surface area and transit time for absorption.•In order to prevent dumping syndrome, theNutritionCareManualrecommendsavoiding simplecarbohydrates such as fruit juices or other foods high in sugar.8.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.oLiquids should be consumed between meals to avoid dumping syndrome. Hydration is important (6-8cups of low-calorie liquid per day).oEat slowly to avoid blockage or nauseaoStop eating when full. This willpreventnausea/vomiting.oVitamin/mineral supplementation is probably warranted.oIf Mr. McKinley had a lap-band procedure,his risk forvitamin and mineral deficiencieswould belowerbecause a lap-band procedure is restrictive but not a restrictive-malabsorptive procedure. A lap-band procedure simply reduces the size of the stomachwithoutbypassingintestinal absorption.oIn addition, the lap-band procedure is adjustable, so food intake can be suited to meet the patient’sneeds.9.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 why intake may beinadequate and 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.•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, a the patient must restrict their food intake to about2-4 Tbspper meal. Protein should be taken first to help with satiety and to aid in healing after surgery. Incase a person cannot tolerate the whole meal, it is important for protein-dense foods to be consumed so theperson does not break down lean body mass when losing weight. Protein malnutrition may also lead tofurther edema 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 Assessment10.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 this.

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2-7•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 and 267lbs.within the first year or two.•Studies also show that 60% of patients typically maintain weight once weight is lostpost-surgery.•Another goal would be to get Mr. Mckinley’s BMI 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.11.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 respiratorymuscles12.Identify any abnormal biochemical indices and discuss the probable underlying etiology. How might theychange after weight loss?•Potassium (high):Serum potassium levels may be elevated post-surgery or could be an acid-baseimbalance. Weight loss may improve levels but it is probably a side effect of the surgery more than obesity.•CPK (high):CPK is an inflammatory marker. This could be due to surgery and destruction of tissue fromthe roux-en-Y surgery. In addition, individuals with chronic obesityoften exhibitchronic inflammation,which may result in higher CPK values. In this case, it is probably due to surgery. Once healing occurs, theCPK value should be improved;weight loss may also help.•Glucose(high):Because ofuncontrolledtype 2 diabetes. Obesity contributes to uncontrolled blood glucoselevels and obesity is a major risk factor for type 2 diabetes. Glucose values willprobably decrease withsignificant weight loss.•HbA1c(high):Average blood glucose over 8-12 weeks. High due to uncontrolled diabetes. High bloodglucose allows for more hemoglobin to be glycated with glucose. May improve or be lowered with weightloss as glycemic control can be helped by weight reduction.•HDL (low):Obesity is positively associated with dyslipidemia, which would explain low HDL levels. HDL(high density lipoproteins)remove cholesterol from the body tissues and bring it back to the liver.•LDL (high):Obesity is associated with hyperlipidemia, which is why the cholesterol or lipid profilenumbersare out of range.An alteration in lipid metabolismoccursin obesity, which may decrease theactivity of the lipogenic enzyme that down-regulates LDL receptors. Lipid profiles tend to be normalized asindividuals reach a more optimal weight.•Triglycerides (high):An excess amount of fat or obesity contributes to high TG levels. Most of the fatfrom food is consumed in triglyceride form.•Cholesterol (high):Same reasoning as LDL and other lipid profile values. Value will probably decreaseonce weight loss is achieved.13.Determine Mr. McKinley’s energy and protein requirements. Explain the rationale for the method you usedto calculate these requirements.•Mifflin-St. Jeor used to calculate energy needs according to theNutritionCareManual under “bariatricsurgery.”•RMR(men)= (9.99actual weightin kg) + (6.25heightincm)–(4.92age) + 5wt.= 410lbs.or 410lbs./2.2=186 kg; ht. = 70 in.2.54 = 177.8 cm

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