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Week 9 Assignment: Nutrition Assessment of Bariatric Surgery Patient

Heather Strait

Logan University

NUTR06202: Clinical Nutrition in Human Systems II

Dr. Devorah Lucas

July 10, 2022

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Week 9 Assignment: Nutrition Assessment of Bariatric Surgery Patient

I. Understanding the Diagnosis and Pathophysiology

1. Classification of obesity

Obesity is defined as a body mass index (BMI) ≥30.0 and body fat ≥25% in men (≥30 in

women). Morbid obesity (Class III obesity) is defined as a BMI ≥40 (Raymond & Morrow,

2021, p. 401).

2. Health risks

Health risks of obesity include heart disease, hypertension, type 2 diabetes mellitus

(TD2M), stroke, gallbladder disease, infertility, sleep apnea, hormonal cancer, osteoarthritis

(Raymond & Morrow, 2021, p. 401), non-alcoholic fatty liver disease (NAFLD), and

hyperlipidemia (NIDDKD, 2018). Mr. McKinley’s history indicates T2DM, hypertension,

hyperlipidemia, osteoarthritis. His laboratory analysis reveals elevated creatine phosphokinase

(CPK) enzymes, indicating myocardial cell death (Copstead & Banasik, 2010, p. 439) and risk of

heart attack.

3. Criteria for bariatric surgery

According to Raymond & Morrow (2021, p. 411), standard adult criteria for

consideration for bariatric surgery are that the patient must have failed to succeed in a

“comprehensive” program that includes counseling, calorie reduction, exercise, lifestyle

modification, and family involvement. Mr. McKinley has failed to maintain weight loss

numerous times in the past and is a good candidate for bariatric surgery (Raymond & Morrow,

2021, p. 411).
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4. Example of a bariatric surgery program

Dartmouth Hitchcock Medical Center and Clinics (2022) offer a bariatric surgery

program. Qualifications for this program are derived from the National Institutes of Health (NIH)

and include a BMI ≥40 or BMI 35-40 in individuals with a high risk for serious obesity-related

conditions that could result in death (Dartmouth Hitchcock Medical Center and Clinics, 2022).

Dartmouth Hitchcock Medical Center and Clinics (2022) offers free informational sessions for

individuals considering bariatric surgery and link to the American Society for Metabolic and

Bariatric Surgery (ASMBS) website for more information on bariatric surgery. The DHMCC

hospital located in Lebanon, New Hampshire has a team of three surgeons and a “full supporting

team” (DHMCC, 2022).

5. Bariatric surgical procedures

a. Roux-en-Y gastric bypass staples the stomach to reduce it to a fraction of its normal size

then connects an opening in the stomach directly to the small intestine via an intestinal

loop (Raymond & Morrow, 2021, p. 411). Potential advantages of Roux-en-Y surgery

include an improvement of cholesterol, blood pressure, and T2DM biomarkers (NIDDK,

2020). Roux-en-Y may even enable the patient to eliminate or reduce medications that

treat hypertension and diabetes (Marchetti et al., 2020). Potential disadvantages

immediately following surgery include surgical complications (potentially leading to

death), diarrhea, blood clots, and gallstones (NIDDK, 2020). In the long term, Roux-en-Y

surgery may result in vitamin and mineral deficiencies, strictures, hernias, and gallstones

(NIDDK, 2020). Nutritional supplementation is necessary to avoid deficiency in B1, B12,

B9, iron, fat soluble vitamins, zinc, and copper (Raymond & Morrow, 2021, p. 412;

Swiley, 2008).
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b. A vertical sleeve gastrectomy, 80% of the stomach is surgically removed and a banana-

shaped stomach remains (NIDDK, 2020; Raymond & Morrow, 2021, p. 411). Potential

advantages of the vertical sleeve gastrectomy include no changes to the intestine, a short

hospital stay and weight loss (NIDDK, 2020). Potential disadvantages include surgical

complications (potentially leading to death), acid reflux, hiatal hernia, and vitamin and

mineral deficiencies (NIDDK, 2020). Supplementation of B1, B6, B12, calcium is

necessary following a vertical sleeve gastrectomy (Emile & Elfeki, 2017).

c. Adjustable gastric banding involves placing an inflatable band around the top part of the

stomach (NIDDK, 2020). Potential advantages include weight loss and negligeable risk

of nutritional deficiencies (NIDDK, 2020). Potential disadvantages include discomfort,

frequent doctor visits to adjust the band, and complications resulting of slippage of the

band.

6. Bariatric surgery and T2DM

Bariatric surgery drastically reduces the amount of food that can be eaten, which

improves T2DM (Naslund & Krai, 2006). Bariatric surgery also alters the secretion of intestinal

hormones that regulate insulin secretion and glucose control (Papamargaritis & le Roux 2021),

which appear to play a role in T2DM reversal. Weight loss also improves biomarkers for

cholesterol, heart disease, and blood pressure (NIDDKD, 2020).

Understanding the nutrition therapy

7. Digestion and absorption following Roux-en-Y

Following a Roux-en-Y procedure, food bypasses the duodenum and is dumped directly

into the jejunum of the small intestine (Raymond & Morrow, 2021, p. 411). If too much food is
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consumed at one meal, the patient will experience tachycardia, sweating, and abdominal pain,

which is supposed to discourage the patient from overeating (Raymond & Morrow, 2021, p.

411). Digestion and absorption of proteins and amino acids is accelerated (Bojsen-Møller et al.,

2015). Because the duodenum is skipped, certain vitamins and minerals are not able to be

absorbed (i.e. B1, B12, B9, iron, fat soluble vitamins, zinc, and copper, therefore nutritional

supplementation is required (Raymond & Morrow, 2021, p. 412; Swiley, 2008). Nutritional

deficiencies also occur in patients following the vertical sleeve gastrectomy and adjustable

gastric banding, and permanent nutritional supplementation is also required for those patients.

8. Avoiding sugar

Sugar must be avoided for two weeks following a Roux-en-Y to avoid painful symptoms

associated with dumping syndrome. Dumping syndrome is caused by a spike in insulin that is

required to digest sugar which then leads to hypoglycemia 1-3 hours after eating (van Beek et al.,

2017).

9. Diet goals following bariatric surgery

Major goals for the Roux-en-Y patient include eating a balanced diet, preventing

nutritional deficiencies through supplementation, restricting caloric intake to lose weight, and to

avoid complications that will arise by eating too much at once (Mechanick et al., 2019). Patients

who undergo a lap-band procedure must also eat smaller meals to avoid pain, restrict total caloric

intake to lose weight, eat a balanced diet (such as the Mediterranean Diet), and supplement to

avoid nutritional deficiencies. Risk of nutritional deficiencies are different for lap-band vs. Roux-

en-Y patients. For example, lap-band patients are not at risk for copper, zinc, B9, or selenium

deficiency, while Roux-en-Y patients are (Mechanick et al., 2019).

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10. Post-operative deficiencies: Protein, water, calcium, iron, and B12

Nutritional deficiencies in protein, water, calcium, iron, and B12 are expected in

individuals who have undergone a Roux-en-Y procedure. Protein deficiency occurs due to

decreased dietary intake of protein, especially immediately following the Roux-en-Y procedure,

but also long term as overall caloric intake is permanently reduced. Dehydration may occur

because drinking water quickly is painful following the Roux-en-Y procedure and liquids must

be slipped slowly, constantly throughout each day.

Calcium deficiency occurs because calcium is primarily absorbed in the upper part of the

small intestine, part of which is permanently bypassed following a Roux-en-Y procedure. In

addition, oral proton pump inhibitors also inhibit absorption of calcium (Mechanick et al., 2019).

Clinical signs of calcium deficiency include numbness and tingling of extremities, muscle

weakness, confusion, seizures (Raymond & Morrow, 2021, p. 34), and muscle cramping

(Swiley, 2008).

Iron deficiency occurs due to reduced intake of dietary iron (red meat), reduced surface

area in the intestine where absorption takes place, and reduced gastric juices (Ruz et al., 2009).

Clinical symptoms include anemia, fatigue, hair-loss, feeling cold, pagophagia, pica, and

decreased immune function (Raymond & Morrow, 2021, pp. 657-658; Swiley, 2008).

B12 deficiency occurs due to decreased stomach acid, use of proton pump inhibitors,

decreased intake of dietary B12, malabsorption due to loss of intrinsic factor (Mechanick et al.,

2019; Swiley, 2008), and an increased demand for B12 during rapid weight loss (Swiley, 2008).

There is also an increase in physiologic demand for B12 during rapid weight loss. Clinical signs
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of B12 deficiency include numbness and tingling of extremities, memory loss, and overall

neurological impairment (Swiley, 2008).

14. Energy and protein requirements to promote weight loss

Mr. McKinely should aim to consume 60-105 g/day of protein (Mechanick et al., 2019;

Swiley, 2008) and a total of 1,000-1,400 kcal/day (Swiley, 2008). Eating less than 1,000 kcal/day

will trigger starvation response and slow metabolism and is not recommended (Swiley, 2008).

IV. Nutrition Diagnosis

15. Two nutrition problems and diagnoses

Nutrition problem #1) malabsorption of key vitamins and minerals.

Nutrition diagnosis #1) Malabsorption of vitamins B1, B6, B9, B12, iron, and calcium

related to gastric bypass surgery as evidenced by laboratory analysis.

Nutrition problem #2) Inadequate protein intake related to gastric discomfort as

evidenced by patient testimony.

V. Nutrition Intervention

16. Post-surgical diet and supplementation

Days 1 & 2: clear liquid diet, no sugar

Days 3-14: liquid diet 60 g protein/day, no sugar

Days 15-30: pureed foods 60 g protein/day, no sugar

Weeks 5-6: chopped foods, comprising 60 g protein/day, low sugar

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Weeks 7+: chopped solids, chew slowly, 60 g protein/day low sugar; eat protein first; no

liquids 30 minutes before or after meal

Supplements: chewable calcium, iron, liquid B vitamin complex

17. Lifestyle changes

Mr. McKinley must engage in 150-300 minutes/week physical activity (Mechanick et al.,

2019)

18. Assessment of readiness for change

Mr. McKinley’s readiness for a physical activity plan will be assessed through patient

interview. Exercise is mandatory following gastric bypass and increases metabolism.

VI. Nutrition monitoring and evaluation

19. Monitoring post-operative nutritional status

A food journal is the ideal way to monitor Mr. McKinley’s nutrition intake. Long-term

laboratory analysis for key nutrients is necessary to ensure that Mr. McKinley is not deficient in

certain vitamins and minerals.

20. Success rate of bariatric surgery

Successful outcomes of bariatric surgery depend largely on patient’s adherence to

physical activity, adoption of healthy eating pattern, and vitamin supplementation (Mechanick et

al., 2019). Individuals with disordered eating patterns, depression, and preference for sweets

have the least success of weight loss following bariatric surgery (Mechanick et al., 2019).
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References

American Society for Metabolic and Bariatric Surgery (ASMBS). (2022). Treat your obesity:

Patient learning center. https://asmbs.org/patients

Bojsen-Møller, K. N., Jacobsen, S. H., Dirksen, C., Jørgensen, N. B., Reitelseder, S., Jensen, J. E.,

Kristiansen, V. B., Holst, J. J., van Hall, G., & Madsbad, S. (2015). Accelerated protein

digestion and amino acid absorption after Roux-en-Y gastric bypass. The American

Journal of Clinical Nutrition, 102(3), 600–607. https://doi.org/10.3945/ajcn.115.109298

Copstead, L. C. & Banasik, J. L. (2010). Pathophysiology (4th ed.). Elsevier. 

Dartmouth Hitchcock Medical Center and Clinics (DHMCC). (2022). Bariatric Surgery Program.

https://www.dartmouth-hitchcock.org/bariatric

Emile, S. H. & Elfeki, H. (2017). Nutritional deficiency after sleeve gastrectomy: A

comprehensive literature review. European Medical Journal 6(1), 99-105

Marchetti, G., Ardengh, A. O., Colombo-Souza, P., Kassab, P., Freitas-Jr, W. R., & Ilias, E. J.

(2020). The effect of Roux-en-Y gastric bypass in the treatment of hypertension and

diabetes. Revista do Colegio Brasileiro de Cirurgioes, 47, e20202655.

https://doi.org/10.1590/0100-6991e-20202655

Mechanick, J. I., Apovian, C., Brethauer, S., Garvey, W. T., Joffe, A. M., Kim, J., Kushner, R. F.,

Lindquist, R., Pessah-Pollack, R., Seger, J., Urman, R. D., Adams, S., Cleek, J. B.,

Correa, R., Figaro, M. K., Flanders, K., Grams, J., Hurley, D. L., Kothari, S., Seger, M.

V., … Still, C. D. (2019). Clinical practice guidelines for the perioperative nutrition,

metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019

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update: Cosponsored by American Association of Clinical Endocrinologists/American

College of Endocrinology, The Obesity Society, American Society for Metabolic &

Bariatric Surgery, Obesity Medicine Association, and American Society of

Anesthesiologists - Executive summary. Endocrine Practice: Official Journal of the

American College of Endocrinology and the American Association of Clinical

Endocrinologists, 25(12), 1346–1359. https://doi.org/10.4158/GL-2019-0406

Naslund, E. & Krai, J. G. (2006). Impact of gastric bypass surgery on gut hormones and glucose

homeostasis in type 2 diabetes. Diabetes, 55(Supplement 2).

https://doi.org/10.2337/db06-S012

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD). (2018). Health

risks of overweight and obesity. https://www.niddk.nih.gov/health-information/weight-

management/adult-overweight-obesity/health-risks

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD). (2020). Types of

weight-loss surgery. https://www.niddk.nih.gov/health-information/weight-

management/bariatric-surgery/benefits

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD). (2020). Weight

loss surgery benefits. https://www.niddk.nih.gov/health-information/weight-

management/bariatric-surgery/benefits

Papamargaritis, D., & le Roux, C. W. (2021). Do gut hormones contribute to weight loss and

glycaemic outcomes after bariatric surgery? Nutrients, 13(3), 762.

https://doi.org/10.3390/nu13030762
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Raymond, J. L. & Morrow, K. (2021). Krause and Mahan’s food & the nutrition care process

(15th ed.). Elsevier.

Ruz, M., Carrasco, F., Rojas, P., Codoceo, J., Inostroza, J., Rebolledo, A., Basfi-fer, K., Csendes,

A., Papapietro, K., Pizarro, F., Olivares, M., Sian, L., Westcott, J. L., Hambidge, K. M.,

& Krebs, N. F. (2009). Iron absorption and iron status are reduced after Roux-en-Y

gastric bypass. The American Journal of Clinical Nutrition, 90(3), 527–532.

https://doi.org/10.3945/ajcn.2009.27699

Swiley, D. (2008). Micronutrient and macronutrient needs in Roux-en-Y gastric bypass patients.

Bariatric Times. https://bariatrictimes.com/micronutrient-and-macronutrient-needs-in-

roux-en-y-gastric-bypass-patients/

van Beek, A. P., Emous, M., Laville, M., & Tack, J. (2017). Dumping syndrome after esophageal,

gastric or bariatric surgery: Pathophysiology, diagnosis, and management. Obesity

Reviews: An Official Journal of the International Association for the Study of

Obesity, 18(1), 68–85. https://doi.org/10.1111/obr.12467