Case-1-2 Pediatric Weight Management – Medical Nutrition Therapy: A Case-Study Approach : Book Guide

This Document Contains Cases 1 to 2 Case 1 – Pediatric Weight Management I. Understanding the Disease and Pathophysiology 1. Current research indicates that the cause of childhood obesity is multifactorial. Briefly outline how genetics, 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 95th. • Jamey would be classified as obese. The CDC and others regard this child to be in the highest weight classification for age. • The approximate optimal weight for Jamey’s age is 70-72 lbs and her approximate optimal height for age is 55 in. 8. Identify two methods for determining Jamey’s energy requirements other than indirect calorimetry, and then use them to calculate Jamey’s energy requirements. What calorie goals would you use to facilitate weight loss? • Total Energy Expenditure, or TEE (for weight maintenance in overweight ages 3-18 years): ○ TEE = 389 – (41.2  age[y]) + PA  (15  weight [kg] + 701.6  height [m]) Where PA is the physical activity factor: PA = 1.00 if physical activity level (PAL) sedentary PA = 1.18 if PAL low active PA = 1.35 if PAL active PA = 1.6 if PAL very active ○ TEE = 389 – 41.2(10) + 1[15(52.3 kg) + 701.6(1.45 m)] ○ TEE = 389 – 412 + 785 + 1017 ○ TEE = 1779 or round to 1800 kcal/day for ease • kcal/cm ○ 12-15 kcal/cm for very low energy needs (sedentary) ○ 12 × 145 = 1740 kcal ○ 15 × 145 = 2175 kcal • For weight loss deduct 108 kcal/day (= 1 lb wt) 9. Dietary factors associated with increased risk of overweight are increased dietary fat intake and increased calorie-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’s 24-hour recall. • Total kcal: ~ 4419; 44% fat, 42% CHO, and 14% protein • Fluid kcal: ~ 957; 22% of kcal 11. Increased fruit and vegetable intake is associated with decreased risk of overweight. What foods in Jamey’s diet fall into these categories? Apple juice, fried okra, and potatoes are the only fruit and vegetables she consumed. 12. Use the Choose MyPlate online tool (available from www.choosemyplate.gov; click on “Daily Food Plans” under “Super Tracker 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): ○ AM: 1 c frosted shredded wheat with 4-8 oz skim milk, 1 c orange juice, and whole-wheat bagel (can use a tbsp of cream cheese or butter if desired). Drink at least 8 oz of water. ○ Lunch: PB&J sandwich (use whole-wheat bread), 15 wheat thins (or 21 small pretzels), 8 oz skim milk. ○ After-school snack: Turkey sub (2 or 3 slices of deli turkey, spinach, and 1 tbsp low-fat Ranch on hoagie or preferably whole-wheat bread), 8 oz skim milk. Drink at least 8 oz water. ○ Dinner: Beef burrito (2 oz ground beef, 1 oz refried beans, 1 oz salsa, 1 oz cheddar cheese), dress with tomato, lettuce, onion, corn. 20 oz water (or 12 oz juice). ○ Snack: 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 Super Tracker online tool (http://www.choosemyplate.gov/supertracker-tools/supertracker.html). Does your menu meet macro- and micronutrient recommendations for Jamey? Answers will vary according to the answer to #12. 14. Why did Dr. Lambert order a lipid profile and blood glucose tests? What lipid and glucose levels are considered altered (i.e., outside of normal limits) for the pediatric population? Evaluate Jamey’s lab results. • The combination of being overweight, nightly urination, HTN, and increased appetite along with a family history of gestational diabetes are clues that there 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 to screen for additional risk factors that can be controlled early on. • Altered lab results: * Total Cholesterol > 170 mg/dL LDL Cholesterol > 110 mg/dL HDL Cholesterol ≤ 35 mg/dL Triglycerides ≥ 150 mg/dL Glucose 60-100 mg/dL • Cholesterol and triglycerides are WNL. • LDL and HDL levels are close to being outside of the acceptable range. • The glucose level is just outside normal range, but she just ate breakfast two hours before she came in. To be 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 Diagnosis 15. 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 nutrition diagnoses 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 beverages such as whole milk, regular sweetened sodas, and fried foods as evidenced by typical daily caloric intake of approximately 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 the problem.) Behavioral/Environmental: • Physical inactivity related to overweight, fatigue, and limited PA at school as evidenced by usual activities limited to playing video games and reading • Undesirable food choices related to knowledge deficit and low intake of fruits and vegetables as evidenced by frequent intake of juices, whole milk, sweetened beverages, refined carbohydrates, fried foods, and high-fat meals • Food- and nutrition-related knowledge deficit as evidenced by Jamey’s mother inquiring about the use of food rewards to motivate an increase in physical activity and exercise (in this case an etiology may not be necessary) V. Nutrition Intervention 16. What behaviors associated with increased risk of overweight would you look for when assessing Jamey’s and her 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 be assessed. • Parents restriction of highly desired food (may lead to overeating when food is available) • 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 a regular 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 help for them to not let Jamey snack between meals and to reward her with dessert when she exercises. What would you tell the family regarding snacks between meals and rewards with dessert after exercise? • Snacks between meals are acceptable as long as they are healthy snacks. ○ Fruits and vegetables would be ideal. ○ Foods with mix of protein, carbs, fat, and fiber may help prolong satiety ○ Portion control for snacking • Instead of using dessert as a reward, Jamey’s mother should offer to do some kind of activity like going to the park or shopping with her—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. • In inclement 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 appropriate intervention (based on etiology). Clinical: • Overweight related to physical inactivity and excessive energy intake as evidenced by BMI of 24.9 Ideal Goal: BMI within normal range and less than 85th percentile Intervention: Nutrition counseling with focus on behavioral modification (refer to specific interventions associated with the intake and behavioral problems defined below). Intake: • Excessive energy intake (or oral food/beverage intake) related to snacks and meals consisting of calorically dense foods and beverages such as whole milk, regular sweetened sodas, and fried foods as evidenced by typical daily caloric intake of approximately 4400 kcal compared to recommended daily intake of 1800-2000 kcal Ideal Goal: Average daily kcal intake within recommended range of 1800-2000 kcal Intervention: 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 grains Behavioral/Environmental: • Physical inactivity related to overweight, fatigue and limited PA at school as evidenced by usual activities limited to playing video games and reading Ideal 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 be designed to lessen signs and symptoms; therefore, nutrition counseling would use the strategies of goal setting, rewards and reinforcement (not foods), and social support to promote physical activities that are realistic and appropriate for both Jamey and her parents. Students should include in their answer the need for 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 evidenced by frequent intake of juices, whole milk, sweetened beverages, refined carbohydrates, fried foods, and high-fat meals. Ideal Goal: Even though this PES statement is quite similar to the intake example noted above, the goals would be defined slightly differently. Instead of a specific caloric goal, goals for this PES would be based on the amount and type of foods described in the signs and symptoms, such as “no more than 4 oz of fruit juice daily” or “limit fried foods to one time weekly,” etc. Intervention: A similar intervention as noted in the intake section above is appropriate as well. • Food- and nutrition-related knowledge deficit as evidenced by Jamey's mother inquiring about the use of food rewards to motivate an increase in physical activity and exercise Ideal Goal: Jamey’s mother providing appropriate non-food rewards to motivate an increase in physical activity Intervention: Nutrition education stating the purpose and use of family counseling theory and strategies that 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 Library from the Academy of Nutrition and Dietetics, what are the recommendations regarding gastric bypass surgery for the pediatric population? The Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity include 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 care provider • Severely obese (BMI 40 or greater) with serious obesity-related medical complications or have a BMI of 50 or 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 15 years of age for boys). • Demonstrate commitment to comprehensive medical and psychological evaluations both before and after weight-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 as immediate and long-term post-operative follow-up care Potential candidates should be referred to centers with multi-disciplinary weight-management teams that have expertise in meeting the unique needs of obese adolescents. Surgery should be performed in institutions equipped to meet the tertiary needs of severely obese patients that collect long-term data on the clinical outcomes of these patients. VI. Nutrition Monitoring and Evaluation 21. 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 be implemented after the intensive phase of treatment • More contact between the patient and RD may lead to more successful weight loss and maintenance 22. 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 the professional'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 behavior strategies. • Parental modeling has advantages in children under 12 years of age • Components include: ○ nutrition education on lifestyle behaviors and their relationship to chronic disease development ○ modification of the home/school environment to enable the adolescent to make wise food choices ○ self-monitoring and motivation to change by modeling behaviors and contracting 23. What would you assess during a follow-up counseling session? When should this occur? • Accurate measurement of height and weight, plotted on 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/recall ○ type of physical activity adolescent participates in ○ type of physical activity parents participate in ○ time 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 weeks may be more realistic) Case 2 – Bariatric Surgery for Morbid Obesity I. Understanding the Disease and Pathophysiology 1. Define the BMI and percent body fat criteria for the classification of morbid obesity. What BMI is associated with morbid obesity? • Body mass index (BMI) is usually used as a common method for determining if someone is obese since it is easy and quick. BMI>30 is considered obese. • Obesity can be defined as a fat percentage greater than ≥25% fat in males and ≥33% in females. However, this requires tools and skill so BMI is more commonly used even though BMI does not factor in body composition. The National Institutes of Health do not recognize percent body fat as criteria for morbid obesity. • 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 95th percentile or ≥30 kg/m2 (whichever represents the lower weight) is considered an obese classification. • The Dietary Guidelines for Americans have different classifications for obesity. Class 1 is a BMI of 30-34.9; class 2, a BMI of 35-39.9; 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. A waist circumference >40 in. men or >35 in. in women indicates obesity or increased risk for CVD. This is based on the fact that central adiposity is thought to propose a higher risk for CVD than gynoid obesity. 2. List 10 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 as prevalent among obese persons compared to those with normal weight • Hypertension (high blood pressure): 3 more common in the obese • Dyslipidemia (abnormal lipid profile, high cholesterol, low HDL, high LDL, high triglycerides) • Gallstones: 6 greater risk 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 ovarian cancers. • 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 density Health risks Mr. McKinley presents with: • Osteoarthritis • Type 2 diabetes • Hyperlipidemia • Hypertension • Metabolic Syndrome (TG ≥ 150 mg/dL, HDL 40) and he has 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 the personnel 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.html Qualification 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 as anemia, Crohn’s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and other complex medical conditions • People who need to take anti-inflammatory medications; VSG presents a lower risk for development of ulcers after taking anti-inflammatory meds after surgery Personnel 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 to 41% for the 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 bypass Description: • 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, which bypasses the rest of the stomach, the duodenum, and the first part of the jejunum in order to restrict digestion and absorption. • The proximal end of the jejunum that is draining the stomach is surgically connected to the lower end of the jejunum, allowing for secretions from the liver, gallbladder and the pancreas to enter the jejunum to aid in digestion and absorption. Advantages: • Weight loss is achieved through this procedure by decreasing food intake, increasing satiety, and deceasing 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 lifestyle changes. • Nutrient deficiencies are more common because it is a restrictive-malabsorptive procedure, especially for fat-soluble vitamins (A, D, E, K), vitamin B12, folate, iron, and calcium. ○ The stomach is being bypassed, which results in loss of intrinsic factor, which is necessary for B12 absorption. ○ The stomach provides acidity for iron absorption, which may be impaired following this procedure. 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 eating refined carbohydrates) b. Vertical sleeve gastrectomy Description: • Up to 85% of the stomach is removed but leaves the pylorus intact and preserves the stomach’s function. • There is a tubular portion of the stomach between the esophagus and the duodenum, restricting remaining stomach’s holding capacity to 50-150 mL. • The surgeon places two rows of staples through both walls of the stomach and then cuts through both walls 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 a restrictive procedure. Advantages: • Minimal nutrient malabsorption. • Removing part of the stomach results in a loss of the hormone ghrelin, which further enhances weight loss 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 a decrease in food intake. • Procedure is not reversible. • High-BMI candidates will most likely need a second procedure to aid in further weight loss. VSG acts as a beginning surgery. Potential complications: Leaks related to the stapling procedure may occur. c. Adjustable gastric banding (Lap-Band®) Description: • Silicone ring or band is laparoscopically introduced into the abdominal cavity and secured around the upper part of the stomach to create a small pouch with a narrow opening at the bottom of the pouch through which food passes into the rest of the stomach. • The band restricts the stomach’s capacity to as little as 30 mL. • 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 delays gastric 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 than for the 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 practice Disadvantages: Patients lose weight at a slower rate than after restrictive-malabsorptive procedures such as the 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 gastroplasty Description: Upper portion of stomach is stapled with a one-centimeter hole at the bottom of the pouch that allows for a very slow passage of food into the lower portion of the stomach. This procedure restricts overall oral intake due to the stomach’s decreased capacity, 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 bypass and the pouch may stretch over time. 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 switch Description: • 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 pancreatic juices to inhibit absorption of energy-yielding nutrients. • The pathways are then re-joined before the large intestine, bypassing a lot of the absorption in the small intestine. Advantages: • Keeping the pyloric valve intact reduces the risk for dumping syndrome. • Significant weight reduction. Disadvantages: • More aggressive procedure, which means more complications associated with the procedure. • Heavy dietary restrictions. Potential complications: • Leaks • Blood clots • Bowel obstruction • Abscesses • Kidney failure • Bleeding • Pneumonia • Infection • Osteoporosis • Anemia • Deficiencies of vitamin A, calcium, vitamin D, and protein f. Biliopancreatic diversion Description: • 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 small intestine to aid in digestion and absorption. Advantages: Greatest amount of weight reduction Disadvantages: Usually only performed on patients with BMI >50 Potential complications: See complications for duodenal switch 6. Mr. McKinley has had type 2 diabetes for several years. His physician shared with him that after surgery he will not be on any medications for his diabetes and that he may be able to stop his medications for diabetes altogether. Describe the proposed effect of bariatric surgery on the pathophysiology of type 2 diabetes. What, if any, other medical conditions might be affected by weight loss? • Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) stimulate insulin secretion. GLP-1 also suppresses glucagon and slows gastric emptying, which delays digestion and reduces postprandial glycemia. GLP-1 also acts on the hypothalamus to induce satiety. Bariatric surgery increases the levels of these hormones and are hypothesized to dramatically improve glycemic control post-operatively. • Weight loss 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 and helps prevent hyperglycemia. • Other conditions that may be affected by weight loss include cardiovascular disease. If hyperglycemia can be controlled, it may reduce the damage to the blood vessels, which aids in reducing risk of cardiovascular disease. • Sleep apnea will be improved with weight reduction, as there is less mass around the respiratory muscles. • Hyperlipidemia can be improved. As the patient eats more consistently with a decreased capacity, lipid profiles may begin to normalize as the patient loses weight. • Blood pressure can be lowered with weight reduction, aiding in resolving hypertension. • May reduce risk of cancer as obesity is linked with some forms of cancers • May improve psychological health as obesity is associated with feelings of guilt, depression, anxiety, and low self-worth II. Understanding the Nutrition Therapy 7. How does the Roux-en-Y procedure affect digestion and absorption? Do other surgical procedures discussed in question #5 have similar effects? • Significant section of stomach bypassed, reducing gastric acid needed for promoting the ferrous state of iron (needed for absorption) and reduced intrinsic factor for B12 absorption • Additionally, gastric acid is needed to cleave many minerals and vitamins from other molecular structures and promote their absorbable forms • Duodenum and proximal jejunum bypassed, thus reducing the overall surface area and time for digestion and absorption • Lactose intolerance may transiently occur due to the production of lactase in the removed part of the small intestine; adaptation can occur • Deficiencies in fat-soluble vitamins (A, D, E, K), vitamin B12, folate, iron, and calcium are common • Other surgical procedures like the duodenal switch and biliopancreatic diversion may have similar effects due to their alterations in the GI tract pathways/release of digestive enzymes 8. On post-op day one, Mr. McKinley was advanced to the Stage 1 Bariatric Surgery Diet. This consists of sugar-free clear liquids, broth, and sugar-free Jell-O. Why are sugar-free foods used? • Sugar-free foods are used to prevent dumping syndrome. • Dumping syndrome is characterized by nausea, vomiting, bloating, and diarrhea and is caused by hyperosmolar foods, which are usually simple carbohydrates. • The hyperosmolar foods cause water to be pulled into the intestine. This occurs because part of the intestine is bypassed and the pyloric sphincter is removed in the roux-en-Y procedure, which gives less surface area and transit time for absorption. • In order to prevent dumping syndrome, the AND Nutrition Care Manual recommends avoiding simple carbohydrates 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 small meals. Describe the major goals of this diet for the Roux-en-Y patient. How might the nutrition guidelines differ if Mr. McKinley had undergone a Lap-Band procedure? • Since roux-en-Y is a restrictive-malabsorptive procedure, it is important to consume very small meals, usually 2-4 Tbsp at one time, to decrease the risks of dumping syndrome. 6-8 small meals are needed because the stomach has a very limited capacity. • Other major goals of the diet include: ○ Protein-dense foods (at least 60 g of protein per day); protein helps with the healing process after surgery and it helps with satiety so the patient can recognize that he/she is full before eating too much. Protein should be consumed first at the meal. ○ Avoid high-sugar beverages and foods. Liquids should be consumed between meals to avoid dumping syndrome (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 clear liquids and at least 24 to 30 oz of full liquids; however, once the diet transitions to soft foods, the individual can continue consuming full liquids if he or she chooses but should consume at least 48 to 60 oz of clear liquids daily. • If Mr. McKinley had a lap-band procedure, his risk for vitamin and mineral deficiencies would be lower because a lap-band procedure is restrictive but not a restrictive-malabsorptive procedure. A lap-band procedure simply reduces the size of the stomach without bypassing intestinal absorption. Dumping syndrome is not as significant of a concern; patients eased into larger-sized meals due to small pouch reservoir created within the stomach. • In addition, the lap-band procedure is adjustable, so food intake can be suited to meet the patient’s needs. 10. Mr. McKinley’s RD has discussed the importance of hydration, protein intake, and intakes of vitamins and minerals, especially calcium, iron, and B12. For each of these nutrients, describe why a deficiency may occur and explain the potential complications that could result from deficiency. • Calcium: Since most of the stomach is bypassed, there is a reduction in the gastric acidity that aids in calcium absorption, causing potential deficiencies and risk of osteoporosis. Additionally, calcium salts can form 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 the stomach, which is mostly bypassed in the roux-en-Y procedure, to aid in absorption. Therefore, iron may be malabsorbed and an iron deficiency may occur. Iron deficiency may lead to iron-deficiency anemia. • B12: B12 is absorbed in the ileum, but it requires intrinsic factor, which is released from the stomach. The stomach is mostly out of commission, so the absorption of B12 is affected. B12 deficiency may lead to pernicious anemia and a folate deficiency. • Protein: Since the stomach’s capacity is very limited, the patient must restrict their food intake to about 2-4 Tbsp per meal. Protein should be taken first to help with satiety and to aid in healing after surgery. In case a person cannot tolerate the whole meal, it is important for protein-dense foods to be consumed so the person does not break down lean body mass when losing weight. Protein malnutrition may also lead to further edema and other micronutrient deficiencies. • Hydration: Hydration is key but liquid should be consumed between meals to minimize dumping syndrome. Hydration goes hand in hand with protein intake. With risk of dumping syndrome, excess water could be lost from diarrhea, so it is important to stay adequately hydrated to prevent dehydration. In addition, as one loses weight, water weight will be lost, making hydration very important. III. Nutrition Assessment 11. Assess Mr. McKinley’s height and weight. Calculate his BMI and % usual body weight. What would be a reasonable weight goal for Mr. McKinley? Give your rationale for the method you used to determine this goal weight. • BMI = 703  410 lbs/70 in./70 in.= 59 • % UBW = (410 lbs/434 lbs)  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 = 123 lbs, 410-123 lbs = 287 lbs. 0.35  410 = 143.5 lbs., 410-143.5 = 266.5 lbs. Therefore, since research shows that most patients lose about 30-35% of their weight, it would be reasonable for Mr. McKinley to lose between 123 and 144 lbs. within the first two years. • Studies demonstrate that 60% of patients typically maintain weight once weight is lost post-surgery. • Another goal would be to get Mr. McKinley’s BMI below 30, since evidence shows a significant reduction in the risk for co-morbidities associated with obesity when BMI is less than 30. This is equivalent to a goal weight 30). • Another post-surgery problem may be that the patient may have a hard time consuming adequate protein because the stomach capacity is reduced but the protein needs are increased. ○ Inadequate protein intake related to recent altered absorption and digestion from recent surgery as evidenced by increased estimated protein needs of 75-90 g/day. ○ Nutrition-related knowledge deficit related to changes in diet due to recent RYGB surgery as evidenced by patient reports. V. Nutrition Intervention 16. Determine the appropriate progression of Mr. McKinley’s post-bariatric-surgery diet. Include recommendations for any supplementation that should be prescribed. Post-bariatric surgery diet progressions may vary by institution but generally would include the following: Details of the diet progression are listed here: RYGB Diet Begin Fluids/Food/Supplements Guidelines Stage 1 Postop days 1 and 2 RYGB clear liquids: Noncarbonated, low kilocalories, low sugar, no caffeine, no alcohol Postop day 1: patients undergo a UGI to test for leak; once tested, begin sips of RYGB clear liquids Stage 2 Start postop days 2-3 for 2 weeks (discharge diet) RYGB clear liquids: Variety of no-sugar liquids or artificially sweetened liquids Encourage patients to have salty fluids at home and solid liquids: sugar-free ice pops Plus RYGB full liquids: 40, or > 35 with presence of co-morbities that could be improved with weight loss, and have attained a skeletal maturity for the most part (age 13 for girls and 15 for boys). • Shows willingness to adhere to nutritional guidelines post-op. • Undergone psychological evaluation that shows he/she can handle the emotional effects of surgery. • Must possess decision-making capabilities. 22. Write an ADIME note for your inpatient nutrition assessment with initial education for the Stage 1 and 2 (liquid) diet for Mr. McKinley. 2-23-2012 (1:30 pm) – Roux-en-Y gastric procedure nutrition follow-up Chris McKinley A: 37 YOWM, Dx: morbidly obese. PMH: type 2 diabetes, hypertension, hyperlipidemia, osteoarthritis Meds: Metformin 1000 mg/twice daily; 35 u Lantus pm; Lasix 25 mg/day; Lovastatin 60 mg/day Skin: warm, dry, intact Abdomen: Obese, rash present under skinfolds, BSx4 I/O: + 2200, -2230 mL, net: -30 mL Labs: HbA1c 7.2%, glucose 145, LDL 232, HDL 32, TG 245, cholesterol 320, K+ 5.8, urinalysis: WNL Ht. = 5’ 10” Wt.: 410 lbs. highest wt.: 434 lbs., % UBW: 95%, BMI: 59; IBW 166 +/-10# Estimated energy requirements: 1500-1900 kcal (20-25 kcal/kg IBW) Estimated protein requirements: 90-113 g protein (1.2-1.5 g/kg/IBW) Diet Hx: Not available. Current diet: clear liquids, post-bariatric surgical diet. D: nutrition-related knowledge deficit related to diet changes from recent roux-en-Y gastric bypass as evidenced by patient reports. I: Goals: 1. Restrict calorie intake to accommodate for decreased stomach capacity to facilitate weight loss. ○ Phase 1: Clear liquid diet Post-operative day 1 and 2 • Sugary clear liquids should be avoided to prevent dumping syndrome. • Patient should consume water, broth, unsweetened beverages such as sugar-free apple juice. • Stomach capacity is at about 30 mL maximum at each meal of clear liquids. ○ Phase 2: Full liquid diet (2 weeks) • ≥ 48-64 oz total fluids per day; ≥ 24-32 oz. no sugar clear liquids; plus 24-32 oz. any combination of full liquids ○ Advance to appropriate progression through stages 3 and 4. 2. Patient will begin exercise regimen after consultation with physician or exercise specialist. M/E: 1. Follow-up appointment will be scheduled with health care team. 2. Monitor labs: lipid panel, BUN, Cr, serum electrolytes, CBC, glucose, HbA1c, thiamin, B12, Vitamin D, Vitamin A, zinc, copper, selenium. 3. Monitor weight loss percentage and the rate of weight loss 4. Monitor patient’s adherence to exercise regimen Solution Manual for Medical Nutrition Therapy: A Case-Study Approach Marcia Nahikian Nelms 9781305628663, 9780534524104, 9781133593157