pediatric rotation major case study
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Morbid Obesity and Implications of Bariatric Surgery in the Adolescent
Population
Children’s National Medical Center Case Study Amy Bortnick
1/22/2013
Presentation Outline
Childhood obesity and the indication for Bariatric Surgery
Bariatric Surgery in adolescents
A Case Study of nutrition counseling for an 18 year old female in the IDEAL Outpatient Clinic considering Bariatric Surgery
Clinical Analysis of the patient and her appropriateness for Bariatric Surgery
Conclusion and questions
Childhood Obesity
The Percent overweight children in the United States has almost tripled in the past 30 years.
15.5% of children are estimated to be obese.
50-77% of obese children grow up to be obese adults.
Obesity in both adolescents and adults greatly increases the risk of developing chronic life threatening diseases and can lead to premature death.
Overweight children have a reduced quality of life compared with non-overweight children (1).
Bariatric Surgery in Adolescence
For severely overweight children and adolescents who have tried and failed to lose weight for longer than 6 months through conventional weight loss methods, bariatric surgery may provide a practical alternative for achieving a healthy weight (1).
From 1996-2003, according to recent national trends, the US has seen a great increase in bariatric surgeries performed in adolescents.
There is very little data documenting long term effects of bariatric surgery in adolescents.
Bariatric Surgery in Adolescence
>14 years of age
Tanner development stage 4 or greater
BMI >40 w/ obesity related comorbidity or BMI> 50.
Documented history of obesity for 3 years
Consent
Confirmation by psychologist or psychiatrist
Inclusion Criteria
Choice of Bariatric Surgery Procedure
Laparoscopic Roux-en-Y Gastric Bypass (LGB)
Laparoscopic Adjustable gastric band (LAGB)
Laparoscopic Sleeve Gastrectomy (LSG).
Source:http://www.nationalbariatriclink.org/imgs/surgery_types.jpg
Critical Labs for Bariatric Candidates
fasting glucose hemoglobin A1c liver function lipid profile complete blood counts thyroid function Pregnancy micronutrient deficiencies. Polysomograpy ( patients with sleep apnea) Bone age assessment (younger patients)
Potential Complications
Early Complications: pulmonary embolism, wound infections, stomal stenosis, dehydration and marginal ulcers
Late Complications: small bowl obstruction, incisional hernias, and late weight regain, sub optimal vitamin intake and micronutrient deficiencies.
Gastric Bypass: intestinal leakage, thromboembolic disease, small bowl obstruction, incisional hernia, protein calorie malnutrition, micronutrient deficiencies.
Adjustable Gastric Band: port mal absorption or mal function, tubing leaks, band slippage, infection, band erosion into stomach or esophagus
Pre-Operative Bariatric Diet
Suggested full liquid diet of protein rich supplements for two weeks Been show to result in greater weight loss after
surgery Shrinks the liver, decreasing surgery time Displays ability to adhere to diet and lifestyle
changes
Post Operative Bariatric Diet
First 2-3 weeks: of a liquid diet. Mainly supplements high in protein, low in fat, and
carbohydrates
After 4-6 weeks: Pureed diet
After 6 weeks: Soft regular foods
Vitamin and Mineral Supplements: 2 multivitamin’s daily, calcium, vitamin B12, and additional vitamins/minerals as needed
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Case study
Subjective
XX is an 18 year old female presenting to the IDEAL Clinic with morbid obesity for her second follow up visit accompanied by her mother. She is currently considering bariatric surgery for weight loss. XX was pleasant and interactive during her last visit. She appears morbidly obese with a buffalo hump, acnathosis nigricans, and abnormal hirstuism present on the face.
Diet Prior to Admission
XX admits to trying several diets in the past. Prior to admission she was following a diet that involved having 8 very small-portioned meals a day. Additionally, on 7/4/12 patient became a vegetarian. XX has never seen a dietitian in the past.
PES Statements
Overweight/obesity (N.C-3.3) related to excessive energy intake, and food and knowledge related deficit as evidenced by BMI > 95%, inability to apply some nutrition related recommendations.
Physical Inactivity (NB-2.1) related to lack of value for behavior change or competing values, as evidenced by obesity >97th percentile, infrequent/ low duration exercise, large amounts of sedentary activities e.g. T.V. watching, computer, and phone use and reports of getting tired easily.
Not Ready for Diet/ Lifestyle Change (NB-1.3) related to lack of self efficacy for making change or demoralization from previous failures at change as evidenced by lack of eye contact, lack of focus, and lack of efficacy to make change or to overcome barriers to change
Anthropometrics
Anthropometrics
Height: 5’5”
Weight: 345 lbs.
BMI: 99.5%
BMI percentile: >97th
Growth Evaluation
Weight trends: 11/27: 158.8 kg, 12/18: 156.5 kg, 1/22: 156.6
BMI trends: 11/27 56.93 (>97%), 12/18: 55.38 (>97%), 1/22: 56.28 (>97%).
Height trends: 11/27:167cm, 12/18: 168.1 cm, 1/22: 166.8 cm
Notable Labs
12/44 HgA1c: 5.8 Low HDL: 26 HOMA-IR: 17.9 –elevated, insulin resistant, on
metformin Low Vitamin D: 9.5 (deficient) – on vitamin D
supplements ALT 37
Labs are significant for: impaired fasting glucose, hypertriglyceridemia, low HDL, mild elevation of ALT, and elevated HOMA-IR
Assessment
Estimated Energy Needs Kcals/kg: 31-43/kg ADBW/day: 2223-2438 kcal Grams protein/ kg: 0.8/kcal/kg = 125.8 g protein mL/day to meet maintenance fluid needs:
20/kg/day 3132 ml
Plan/ Goals
Physical Activity Goals Move at least 10 minutes 3/day a week (Tuesday,
Wednesday, Saturday). Nutrition Goals
Pre-op diet for one week (bariatric guide, RD email address provided)
Use meal replacement instead of skipping breakfast
XX and Bariatric Surgery
BMI of 56.28 meets criteria
18 YO meets maturation and bone growth
IDEAL clinic provides multi-disciplinary support (patient is seeing a physician, psychiatrist and RD)
Patient is currently trying to lose weight through nutrition and physical activity without significant success
Mother displays evidence of a supportive family member, respecting the patient’s decision.
However patient shows concern for adherence to dietary demands of bariatric surgery
Patient and mother have been receiving on going education on bariatric surgery
Case Conclusion
It is too early to tell if XX will be appropriate for weight loss surgery. Her personal desire for the surgery as well her efficacy and ability to understand and adhere to dietary restrictions will be critical. However, her current BMI status places her a substantial risk for chronic life threatening conditions, she has documented her weight has interfered with her quality of life. For now the focus is physical activity a healthful diet and the ability to follow a pre-operative diet.
Discussion
More research on bariatric surgery in adolescence is needed to determine long term impacts on overall health and well being.
Israel Study: Comparing inpatient intervention with bariatric surgery
Netherlands Study: Interventional study comparing laparoscopic adjustable band surgery and behavioral therapy
Results of such studies won’t be forth coming for several years
Questions?
Source: http://adiaryofamom.files.wordpress.com/2011/01/ist2_5853965-question-mark.jpg
References
1. Inge T et al. Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations. Pediatrics Vol 114 No. 1 July 2004 217-223.
2. Ingelfinger, Julie. Bariatric Surgery in Adolescents. N Engl Med 365;15
3. Wilson S. Tsai, MD; Thomas H. Inge, MD, PhD; Randall S. Burd, MD, PhD. “Baratric Surgery in Adolescents- Recent National Trends in Use and In-Hospital outcome”. American College of Medicine.
4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;25:869-873. Reousce: http://www.nejm.org/doi/full/10.1056/NEJM199709253371301#t=articleTop
5. University of Michigan Health System: Adult Bariatric Surgery Program. http://www.med.umich.edu/bariatricsurgery/about/bypass/postop.shtml
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