Michelle

Garvie

Bariatric
Case S tudy

March 15, 2015

Answer the following questions:
1. After reading the physicians history & physical, identify any signs or symptoms that are most likely a
consequence of Mr. Cs morbid obesity.
The patients BP (135/90 mmHg) hypertensive stage 1, ecchymosis, abrasions, petechiae on lower
extremities, 2+ pitting edema, rash present under skinfolds, stasis ulcer to right inner ankle are due to his
obesity.
The patients hypercholesterolemia, type II DM, HTN, HLD, and osteoarthritis are also due to his obesity

2. Mr. C has had type 2 diabetes for several years. His physician shared with him that after surgery he will not be
on any medications for his diabetes and that he may be able to stop his medications for diabetes altogether.
Describe the proposed effect of bariatric surgery on the pathophysiology of type 2 diabetes.

The return to euglycemia shortly after surgery is not explained by weight loss alone. Possible mechanisms
for the changes that lead to normalized glucose levels are: decreased food consumption, partial digestion
and absorption of nutrients, and changes to the anatomy of the GI tract (biliopancreatic diversion).

3. Identify any abnormal biochemical indices and discuss the probable underlying etiology.

Hyperkalemia due to stasis ulcer. When tissues are damaged, they release potassium, may be elevated
post-surgery, may be due to stress

CO2 low due to surgery

Glucose due to the patients insulin resistance due to his DM as a consequence of obesity

Albumin slightly elevated due to infection

CRP elevated due to infection

Cholesterol, LDL, TG elevated due to obesity

HDL depressed due to obesity

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

The standard adult criteria to be considered as a candidate for bariatric surgery is:
o

Efforts to lose weight with diet and exercise have proven unsuccessful

BMI is 40 or higher

BMI is 35-39.9 with other comorbidities (maybe as low as 30-34.9 with extreme comorbids)

Age 18-65

Highly motivated and mentally prepared individual

Medically cleared to withstand surgery

Has good understanding of procedure and life-long ramifications

Mr. C has a BMI of 58.8, and the comorbidities of Type II DM, HTN, HLD


Michelle Garvie

Bariatric Case Study

March 15, 2015

5. Conduct a calorie count of Mr. Cs pre-op diet using the Exchange List System.
Typical Diet PTA:
Breakfast: 4 slices wheat bread, 2 tsp. butter, 2 scrambled eggs, 1 banana, 1 cup skim milk
AM Snack: 1 Apple, 2 tbsp. peanut butter, 1 diet Pepsi
Lunch: 2 Tortillas, cup black beans, 1 cup salsa, cup shredded cheese, 1 tbsp. sour cream, avocado, 1 diet Pepsi
PM Snack: cup almonds, 1 Yoplait light yogurt
Dinner: 6 oz. grilled chicken breast, cup brown rice, cup corn, steamed broccoli, 1 dinner roll with 1 tsp. butter, 1
cup skim milk
HS Snack: 1 cup ice cream with cup chopped berries

Breakfast: 320 + 90 + 150 + 100 = 660 kcal

AM snack: 60 + 200 = 260 kcal

Lunch: 160 + 125 + 60 + 90 + 25 + 100 = 560 kcal

PM snack: 180 + 120 = 300

Dinner: 270 + 120 + 80 + 25 + 80 + 45 + 100 = 720

HS snack: 370 + 30 = 400

Total calories: 2,900 kcal

6. Calculate his BMI and % UBW; what would be a reasonable weight goal for Mr. C?

Mr. Cs BMI is 58.8, and his UBW is 434 lbs. His %UBW is 94%. His %IBW is 155%.

A reasonable weight goal for Mr. C would be 60-70% of the excess weight lost, which is common for Roux-
en-Y gastric bypass surgeries. This would be (185.97 kg (BW) - 75.29 kg (IBW)) * 0.6-0.7 = 66-77 kg lost, and a
resulting weight of 108.97-119.97 kg.

30-35% or BW lost 1-2 years post surgery

7. Determine Mr. Cs energy requirements to promote weight loss.

Energy requirements for Mr. C (based on IBW) are 2,250 kcal/day, based on 30 kcal/kg of IBW. To promote
weight loss, Mr. C should consume 1,400-1,600 kcal each day.

8. Describe any pertinent lifestyle changes that you would view as a priority for Mr. C.

I would recommend that Mr. C begin an exercise program, involving walking for 30 minutes every day,
increasing to walking 60 minutes every day after six weeks, and transitioning to 60-90 minutes of vigorous
physical activity each day, as tolerated.

Mr. C should also stop consuming diet soda and other carbonated beverages in the short term, should keep
fat consumption to 24% of kcal, eat breakfast every day, weigh himself regularly at least once each week,
and engage in high levels of PA (after transitioning to becoming physically active) of 60-90 minutes each day.


Michelle Garvie

Bariatric Case Study

March 15, 2015

9. Determine the appropriate progression of Mr. Cs post-bariatric-surgery diet.

Initially, (day 1) Mr. C should consume 30 mL/ hour of a sugar-free, non-carbonated, clear liquids, such as
Crystal Light or sugar-free Kool-Aid, low-fat, clear broths, or water. He should not use a straw when
consuming these beverages, and should sip them.

Day 2 post-op, Mr. C should consume 60 mL/hour of low fat, low sugar, high protein liquids such as skim
milk, strained soup made with skim milk, sugar-free yogurt or pudding, or a bariatric liquid protein
supplement. No ice cream or sherbet should be given.

Day 3 post-op, Mr. C can consume semi-liquid, high protein foods such as skim milk, strained soup made
with skim milk, sugar-free yogurt or pudding, low-fat strained meats thinned with broth, or mashed
potatoes with protein powder. These foods can be consumed at 1 Tbs every 15 minutes, or 2-3 oz per hour.

Post discharge plan for Mr. C is to have 5-6 mini feedings each day, consisting of -1/2 a cup of food at each
meal. These foods should be low fat and low sugar to avoid dumping syndrome. Concentrated sweets are to
be avoided. Mr. C will have a high-protein, low-sugar, low-fat bariatric liquid protein supplement, a liquid or
chewable multivitamin and mineral supplement, a liquid or chewable calcium supplement (1,500 mg calcium
citrate or 2,000 mg calcium carbonate with vitamin D daily).

The progression for Mr. C (depending on tolerance) is:

o

1-2 days after surgery clear liquids only

2-4 weeks after surgery full liquids only

2-4 weeks of pureed, ground, or mechanical soft foods

Transition to a normal diet for the rest of his life

10. List at least 2 short-term (in hospital) and long-term (once discharged) goals.

Initially, (day 1) Mr. C should consume 30 mL/hour of a sugar-free, non-carbonated, clear liquids, such as
Crystal Light or sugar-free Kool-Aid, low-fat, clear broths, or water. He should not use a straw when
consuming these beverages, and should sip them.

Day 3 post-op, Mr. C can consume semi-liquid, high protein foods such as skim milk, strained soup made
with skim milk, sugar-free yogurt or pudding, low-fat strained meats thinned with broth, or mashed
potatoes with protein powder. These foods can be consumed at 1 Tbs every 15 minutes, or 2-3 oz per hour.

A long-term goal would be a 50% reduction in excess weight in 12 months (55.34 kg)
Another long-term goal would be to maintain a low-fat, low-concentrated sugar diet to prevent incidence of
dumping.