Bariatric Surgery: Comprehensive Strategies for Management in Primary Care

Bariatric Surgery: Comprehensive Strategies for Management in Primary Care Twyla Goritz, RN, BSN, NP, and Elsie Duff, NP, MEd, PhD(c) ABSTRACT

Bariatric surgery is an alternative for long-term weight loss that improves quality of life and decreases mortality by reducing or eliminating obesity and the associated chronic diseases. The nurse practitioner’s role is vital in promoting positive long-term outcomes in view of the increased prevalence of patients with bariatric surgery and their need for management in the primary care setting. The obesity epidemic, weightloss surgery options, and strategies to manage risks, benefits, and complications need to be considered in providing primary care. As primary care providers, we must address the gap between the psychological benefits of weight-loss surgery and strategies to prevent weight regain and chemical dependency. Keywords: bariatric surgery, primary care, weight loss surgery Ó 2014 Elsevier, Inc. All rights reserved.

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verweight and obese patients are seen by nurse practitioners (NPs) on an increasing basis. In Canada and the United States, 101,645 bariatric operations were performed in 2011.1 As obesity rates increase globally, long-term management of patients following bariatric surgery is becoming prevalent in primary care practice. The role of the primary care provider is to manage chronic disease and monitor for long-term surgical, metabolic, and psychological complications that may arise. In this article we review the types of bariatric surgery, preand postoperative processes involved, and associated long-term implications. For NPs, a comprehensive understanding of the obesity epidemic, weight-loss surgery (WLS) and inclusion criteria, risks and benefits, and complications of WLS are essential to assist clients in making informed decisions. In what follows we address management of bariatric patients in the primary care setting so NPs can make informed decisions regarding this unique patient population. RISE IN OBESITY EPIDEMIC

As obesity rates increase, NPs will more frequently need to evaluate, refer, and support potential candidates for bariatric surgery. Obesity is a significant www.npjournal.org

health-care problem around the world with over 1 billion overweight adults and 300 million people with a body mass index (BMI) between 30 and 39.9.2 Currently, 34.9% of US adults are obese with a BMI greater than 30, with African American males having the highest rate of obesity at 49.5%.3 Data collected from 1990 to 2008 from the Behavioral Risk Factor Surveillance System projects that obesity rates will reach 51% by 2030.4 Obesity rates are increasing the fastest (75%) among the morbidly obese, those with a BMI greater than 50. Overall, rates have risen among men and women of all ethnic groups, regardless of education and socioeconomic status. The highest prevalence was found within low socioeconomic status African American and Hispanic females.5 Primary care NPs play a vital role in the management of obesity and disease prevention. IMPACT OF OBESITY

Obesity and conditions associated with obesity impact health-care costs, quality of life, and mortality rates. Increased health-care visits create a financial strain with annual costs of $139 billion in the US, comprising 5% of the national health expenditure resources in 2009.6 Projected obesity growth rates The Journal for Nurse Practitioners - JNP

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suggest health-care costs will climb from $861 to $957 billion by 2030.3,4 Annual health-care costs for obese individuals averages $1,429 (42%) higher than normal-weight people.4 Direct health-care costs are impacted by the increased need of medications, hospitalizations, utilization of services, and an indirect cost from work absenteeism, disability, and premature mortality.6 Obese individuals accrue 46% higher hospitalization costs, require 27% more outpatient doctor visits, and spend 80% more on prescription medications than normal-weight patients.7 Cost saving can be achieved with effective primary care of obesity. Obesity is now recognized as a chronic disease, causing an increased likelihood of developing comorbidities, such as diabetes, hypertension, and cardiovascular syndromes.2 The condition is associated with diminished energy, limited physical functioning, poor self-esteem, and body dissatisfaction, leading to higher rates of depression and decreased quality of life (QOL). Deterioration of health and decreased QOL contribute to progression of weight gain and an overall reduced lifespan.2,8 Counseling patients with regard to chronic disease, QOL, and long-term outcomes for obesity are essential components of primary care. Bariatric surgery is the only treatment modality shown to provide consistent, sustained, long-term weight loss and for decreasing or reversing obesityrelated comorbidities, such as type 2 diabetes (80%), dyslipidemia (70%), hypertension (75%), and obstructive sleep apnea (80%) in the morbidly obese population.2 Despite these findings, primary care providers continue to underdiagnose or provide suboptimal management of obesity.9 Given that WLS is the treatment of choice, primary care NPs must diagnose their patients adequately, provide information on obesity treatment options, and assist them in achieving long-term success. Overall, effective care strategies can help decrease health-care costs and improve health outcomes in obesity-related comorbidities. BARRIERS TO OBESITY TREATMENT

Barriers to obesity treatment should be reviewed with patients considering bariatric surgery. Evaluation of potential barriers, such as socioeconomic status, 688

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cultural beliefs, time constraints, lack of a support network, and professional obligations, need to be assessed. Cognitive impairment, sleep disturbances, pain, chronic fatigue, immobility, cardiovascular disease, pulmonary function, and endocrine disorders may all limit a person’s ability to understand and implement the lifestyle changes necessary to achieve long-term weight loss.10 Perceived barriers should be identified within primary care practice to ensure that strategies can be developed to prevent noncompliance and poor weight-loss outcomes. Only 50% of primary care practitioners counsel patients on obesity management. The barriers to counseling patients in weight loss include lack of time, patient noncompliance, inadequate reimbursement, limited teaching materials, and low confidence in surgery as a treatment option for obesity.9 These counseling barriers may explain the lack of necessary documentation and referrals being done for patients. Providers need to shift beliefs of obesity from being a symptom to that of a chronic disease.2,10 Educating primary care providers on obesity may decrease barriers to treatment and improve the care of this patient population. CRITERIA FOR BARIATRIC SURGERY

Obesity classifications are currently based on BMI, which is determined by weight (in kilograms) divided by height (in square meters). Categories of BMI and classes of obesity are presented in Table 1. There is a direct correlation between an increase in BMI and an increased risk to develop others comorbidities, such as diabetes, hypertension, debilitating arthritis, obstructive sleep apnea, cardiovascular disease, dyslipidemia, gastroesophageal reflux, or

Table 1. Class of Obesity Using Body Mass Index (BMI) BMI (kg/m2) Underweight

Obesity Class

< 18.5

Normal

18.5e24.9

Overweight

25.0e29.9

Obesity

30.0e34.9

I

35.0e39.9

II

Extreme obesity

 40

III

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steatohepatitis.3,11 Practitioners should monitor BMI and assess patients for other comorbidities as part of routine health promotion and disease prevention. The National Institute of Health established the BMI criteria for bariatric surgery as BMI 40 or BMI 35 with obesity-related comorbidities.10 Selection criteria for bariatric surgery are outlined in Table 2. A documented history of unsuccessful attempts at weight loss is essential to establish the medical need for bariatric surgery. The patient must: (a) comprehend the benefits and limitations of the procedures offered; (b) agree to take daily supplements; (c) complete routine blood work; (d) be committed to the recommendations of self-monitoring; (e) attend multiple follow-up appointments; and (f) exercise daily.11,12 Practitioners need to have a clear understanding of WLS criteria, inform patients of the commitment requirements, advocate for surgery, document weight-loss attempts, and manage comorbidities to optimize longterm outcomes. BARIATRIC SURGICAL PROCEDURES

Bariatric surgery is categorized by the type of surgery performed. The most common bariatric surgeries are: (1) restrictive (eg, adjustable gastric banding, sleeve gastrectomy); (2) restrictive with some malabsorption (eg, Roux-en-Y gastric bypass, or RYGB); and (3) primarily malabsorptive with some restriction (eg, biliopancreatic diversion, or BPD, with a duodenal switch). The bariatric center staff can provide Table 2. Selection Criteria for Bariatric Surgery Inclusion Criteria Body mass index  40 with no comorbidities. Body mass index  35 with obesity-related comorbidities. Documented failed weight-loss attempts. Patient commitment to:  attend follow-up visits with team members.  adhere to diet, exercise, lifestyle, and supplement recommendations.

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Exclusion Criteria Current drug or alcohol abuse. Uncontrolled or severe psychiatric illness. Lack understanding of bariatric surgery, including:  risk or benefits.  expected outcomes.  lifestyle modifications required.

educational materials and sessions to address the risks and benefits associated with the surgery. Preoperative evaluation includes a complete history, physical examination, laboratory testing, nutritional evaluation, and psychosocialebehavioral assessment to determine appropriate candidates for the surgery.11,12 Long-term excess weight loss averages 40% to 50% with gastric sleeve/banding and 47% to 70% with RYGB or BPD. Mortality rates decrease by 30% to 40% in the 10 years after WLS.13 An understanding of common bariatric surgery will assist NPs in informing their patients about the procedures available, the surgical process requirements, and realistic weight-loss goals. PREOPERATIVE ROLE OF NPS

Primary care NPs can play an instrumental role in assisting and implementing strategies for the bariatric team to prepare the patient for surgery. One strategy primary care NPs can initiate is helping patients to be smoke-free at least 8 weeks before surgery. Early discussions with patients regarding smoking cessation, options available, and support are essential aspects of care before surgery. In addition, maintaining good glycemic control, normalizing blood pressure, achieving lipid targets, and stabilizing chronic disease will lead to the best postoperative outcomes.11 Many presurgical aspects of care can be initiated and managed by primary care NPs. Preoperative weight loss reduces the operating time and the length of hospital stay, as liver size is decreased. As the liver shrinks, the mesenteric fat deposits and abdominal wall depth decrease, allowing for fewer complications during the surgery. Practitioners should assess obese patients for sleep apnea and initiate a sleep clinic referral to ensure that evaluation and treatment of apnea can be started before surgery.11,12 An evaluation of deficiencies, especially anemia, vitamin A, and vitamin D should be assessed and treated earlier in the preoperative phase to prevent worsening of micronutritional deficiencies postoperatively.14 Primary care NPs can readily support weight loss, chronic disease management, and reversal of deficiencies to optimize patient outcome before surgery. The Journal for Nurse Practitioners - JNP

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FERTILITY AND PREGNANCY

Fertility control is a fundamental component of primary care before WLS. Women of reproductive age must be counseled on preoperative contraception.11 WLS results in either a restriction of food ingested, malabsorption of nutrients, or both. The greatest weight loss occurs within the first 12 to 18 months after surgery, so recommendations include waiting a minimum of 12 months prior to conception. Maternal malnutrition can affect the fetus, resulting in a risk for low birth weight and congenital abnormalities. Delaying pregnancy may optimize weight loss and prevent symptoms, such as nausea and abdominal pain, from being confused with a postsurgical complication or early pregnancy.15 Most women do not use any contraception during the first year after bariatric surgery, despite evidence that obese women who have anovulation before surgery are likely to report normal menses after bariatric surgery.16 Counseling on the subject of increased fertility after WLS and the need for preoperative contraception is crucial to support weight loss and prevent fetal anomalies. Reinforcing the risks of pregnancy during WLS and contraceptive management are strategies that can be effectively managed in primary care before surgery. POSTOPERATIVE SURGICAL COMPLICATIONS

Surgical complications can arise postoperatively within hours, days, or months of having surgery. Laparoscopic banding procedures may lead to the development of port dysfunction, gastric or esophageal dilation, band slippage, or obstruction. The combined restrictive and malabsorptive operations (RYGB and BPD) may lead to staple line leaks, bleeding, infections, ulcerations, internal hernias, incisional hernias, bowel obstructions, nausea or vomiting, strictures, and potentially death. After rapid weight loss, there is an increased incidence of gallstone formation and cholelithiasis. Complaints of surgical-site or systemic infection, dysphagia, chest pain, abdominal pain, reflux, or vomiting warrants immediate evaluation by a qualified bariatric surgeon.17 Routine monitoring of patient’s history and physical examination after WLS may identify complications warranting further testing or a referral 690

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back to the bariatric team. The NP combines a holistic approach with client advocacy to provide comprehensive primary care for this unique patient population.18 DUMPING SYNDROME

Dumping syndrome (DS) in malabsorptive procedures results from ingestion of simple carbohydrate foods or liquids, which then rapidly leave the stomach and enter the small intestine too quickly. This results in “dumping” symptoms, such as salivation, sweating, flushing, cramping, nausea, vomiting, diarrhea, tachycardia, and dizziness.19 The symptoms can be severe and frightening to patients. Typically, dumping syndrome is self-limiting and resolves in 1 or 2 hours. The uncomfortable symptoms may be a motivator to promote adherence to diet.20 NPs can reinforce proper diet education to patients by having them avoid sugary, high-carbohydrate foods, eat slowly, and not drinking with meals. NUTRITIONAL DEFICIENCIES

Nutritional deficiencies develop after malabsorptive procedures, but levels should be routinely monitored for all types of bariatric surgery. Deficiencies vary depending on the type of surgery performed, dietary habits, and gastrointestinal symptoms, including nausea, vomiting, or diarrhea.21 Recommended routine laboratory monitoring indications are listed in Table 3. Primary care providers have the capacity to order and monitor the necessary laboratory testing for this patient population. Common deficiencies after WLS could include protein malnutrition, iron deficiency anemia, macrocytic anemia related to folate or vitamin B12, hypocalcemia, and low vitamin A or D levels. Postoperative nutritional recommendations indicate 60 to 120 grams per day of protein to maintain lean body mass and prevent protein malnutrition. Long-term vitamin and mineral supplements are required for bariatric surgery patients to prevent micro- and macronutrient deficiencies.22 Primary care providers in collaboration with bariatric team members can educate patients regarding symptoms to watch for, conduct appropriate assessments, order laboratory studies, and provide supplements as required. Volume 10, Issue 9, October 2014

Table 3. Recommended Routine Nutritional Monitoring Complete blood count Chemistry panel (glucose, calcium, creatinine, electrolytes) Liver function test Albumin Iron and ferritin Vitamin B12 25-Dihydroxyvitamin D Vitamin A Folate Zinc Parathyroid hormone

PSYCHOLOGICAL CONSIDERATIONS

Psychological conditions involving body image dissatisfaction, mood disorders, and eating behavior disorders are common in the obese population. Obesity negatively impacts a person’s physical and mental well-being contributing to weight gain and compounding the severity of obesity.8,23 The psychological benefits of WLS may include improved QOL, self-esteem, and body image, with a decrease in anxiety and depressive symptoms.23 Patients undergoing WLS are at risk to relapse with eating disorders and those with major depression or dysthymia have a higher risk of suicide after surgery.24 An NP in primary care needs to screen patients for mental health concerns, suicidal ideations, or body-image dissatisfaction, and refer high-risk individuals for further intervention. A psychological evaluation is required preoperatively to review environmental factors, behavioral issues, and familial dynamics that affect the psychosocial aspects of patient care. Any known or suspected psychological illness requires a formal mental health evaluation to determine eligibility for WLS.10 Prior mood or eating disorders do not consistently predict barriers to long-term weight loss, but treatment should not be delayed or replaced by surgery. Self-monitoring behaviors increase awareness over increased food urges, binge eating, well-being, decreased mood, or addictive behaviors in prevention of weight www.npjournal.org

regain.25 Health-care providers need to promote self-monitoring behaviors and be vigilant for reemergence of binge-eating or night-eating syndromes. Pre- and postoperative monitoring decreases problems related to surgery. Preoperative counseling provides positive reinforcement of behavior modifications, improves surgery preparedness, and increases compliance to diet and exercise.26 Unrealistic expectations that life will dramatically change after bariatric surgery could have a negative impact on mental health. Monitoring high-risk individuals and referring to mental health professionals with the knowledge and training to assist in adopting healthy behaviors, goal setting, counseling, and utilizing support groups may optimize compliance and long-term weight loss.27 Education aimed at goals to achieve healthy weight loss for reducing mortality and comorbidity may be more effective than obtaining an ideal body weight for this patient population.19 Reinforcing realistic postoperative expectations, providing ongoing support, and counseling promotion should be implemented as routine practice within primary care. ALCOHOL AND SUBSTANCE USE

Current alcohol or substance dependence or abuse is a contraindication for bariatric WLS.11 Alcohol metabolism is altered after WLS, causing rapid absorption of alcohol into the small intestine, and triggering blood alcohol concentration levels to rise quicker. The quick rise in blood alcohol creates a longer intoxication period after surgery, especially with RYGB surgery. The alteration in metabolism may contribute to the increased rates of dependency and abuse in these patients.28 A lifetime history of substance abuse after WLS is 32.6% compared with 14.6% in the rest of the general population.29 Individuals who underwent WLS reported a 28.4% increased use of alcohol postoperatively, typically adhering to behavioral modifications in the first couple of months, but with significantly increased use by 24 months postoperatively.30 Primary care providers must educate patients on the increased risks for dependency after WLS, obtain a baseline social history, and routinely screen for substance use to promote early detection and intervention if warranted. The Journal for Nurse Practitioners - JNP

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LONG-TERM WEIGHT REGAIN

Physical activity pre- and postoperatively is a strategy that leads to better surgical outcomes and improved weight loss, body composition, and overall fitness levels. Counseling on activity should be maintained throughout the WLS process and can predict success for long-term weight loss and maintenance.31 Current guidelines recommend physical activity levels between 200 to 300 minutes per week to minimize long-term weight regain (>1 year).7 NPs should reinforce the importance of adherence to physical activity and reduction of sedentary time to prevent weight regain (WR). Barriers to physical activity from pain due to chronic arthritis, back pain, and neuropathy should be evaluated, and treatments should be provided to help maintain the activity level necessary to sustain longterm weight loss. Other factors contributing to WR include depression, dense caloric alcohol consumption, eating disorders, food urges, and noncompliance with lifestyle modifications.25 Patients should be encouraged to consume proteins first before carbohydrates and fats, eat slowly over at least 20 minutes, and chew food completely to allow the feeling of satiety. Discouraging consumption of alcohol and other high-calorie liquids, avoidance of “grazing” on small portions of high-calorie foods multiple times during the day, and reinforcing positive eating habits and will help maintain weight loss.19 The goal of the NP is to prevent long-term WR by promoting program compliance of diet, activity, and self-monitoring, with referrals to the bariatric team as indicated. MEDICATION CONSIDERATIONS

Alteration of the small intestine done during certain WLS procedures affects the absorption of certain medications. Bariatric patients should be cautioned on the use of nonsteroidal anti-inflammatory agents (including cyclooxygenase-2 inhibitors), or be instructed to use them only in conjunction with a protein-pump inhibitor to prevent gastric ulcers and bleeding. Diuretics can be used, but patients should be closely monitored for dehydration and renal insufficiency. Calcium citrate is better absorbed than calcium carbonate after WLS, thus calcium citrate should be used as the primary calcium 692

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supplement. Psychiatric medications and anticoagulants should be evaluated and doses adjusted due to the alteration in absorption. Last, pill size should be taken into consideration to avoid blocking of the stoma or possible mucosal erosion of the anastomosis sites.32 An extensive medication review should be done in primary care to assess the risks for drug malabsorption and alternatives should be evaluated. CONCLUSIONS

Bariatric surgery provides significant long-term weight loss that improves QOL and decreases mortality by reducing or eliminating obesity and chronic diseases associated with obesity. It is imperative that the NP provides ongoing support to the bariatric client to improve and maintain weight loss success. Knowledge of postoperative complications, thorough assessments, monitoring of appropriate laboratory studies, and adjusting medications are essential in the treatment of bariatric patients in primary care. Primary care NPs play a vital role in promoting positive long-term outcomes by providing comprehensive evaluations and advocating for appropriate referrals for this patient population. References 1. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427-436. 2. Christou NV. Impact of obesity and bariatric surgery on survival. World J Surg. 2009; 14;33(10):2022-2027. 3. Centers for Disease Control and Prevention. Obesity and overweight for professionals: data and statistics: adult obesity. http://www.cdc.gov/obesity/ data/adult.html. Accessed June 16, 2014. 4. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics— 2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292. http://dx.doi.org/10.1161/01.cir.0000441139.02102.80. 5. Catenacci VA, Hill JO, Wyatt HR. The obesity epidemic. Clin Chest Med. 2009;30(3):415-444. 6. Terranova L, Busetto L, Vestri A, Zappa MA. Bariatric surgery: costeffectiveness and budget impact. Obes Surg. 2012;22(4):646-653. 7. Jensen MD, Ryan DH, Donato KA, et al. Executive summary: Guidelines (2013) for the management of overweight and obesity in adults. Obesity. 2014;22(suppl 2):S5-S39. http://dx.doi.org/10.1002/oby.20821. 8. Cameron AJ, Magliano DJ, Dunstan DW, et al. A bi-directional relationship between obesity and health-related quality of life: evidence from the longitudinal AusDiab study. Int J Obes. 2012;36(2):295-303. 9. Afonso BB, Rosenthal R, Li KM, Zapatier J, Szomstein S. Perceived barriers to bariatric surgery among morbidly obese patients. Surg Obes Relat Dis. 2010;6(1):16-21. 10. Mauro M, Taylor V, Wharton S, Sharma AM. Barriers to obesity treatment. Eur J Intern Med. 2008;19:173-180. 11. Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract. 2008;14:1-83. 12. Karmali S, Johnson Stoklossa C, Sharma A, et al. Bariatric surgery: a primer. Can Fam Phys. 2010;56(9):873-879.

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13. Eldar S, Heneghan HM, Brethauer SA, Schauer PR. Bariatric surgery for treatment of obesity. Int J Obes. 2011;35(suppl):S16-S21. 14. Buchwald H, Ikramuddin S, Dorman RB, Schone JL, Dixon JB. Management of the metabolic/bariatric surgery patient. Am J Med. 2011;124(12):1099-1105. 15. Kominiarek MA. Preparing for and managing a pregnancy after bariatric surgery. Semin Perinatol. 2011;35(6):356-361. 16. Mody SK, Hacker MR, Dodge LE, Thornton K, Schneider B, Haider S. Contraceptive counseling for women who undergo bariatric surgery. J Womens Health (Larchmt). 2011;20(12):1785-1788. 17. Lee MJ, Scott DJ. Medical management of postsurgical complications: the bariatric surgeon’s perspective. Gastrointest Endosc Clin N Am. 2011;21(2):241-256. 18. Heinlein CR. Dumping syndrome in Roux-en-Y bariatric surgery patients: are they prepared? Bariatr Nurs Surg Patient Care. 2009;4(1):39-47. 19. Doolen JL, Miller SK. Primary care management of patients following bariatric surgery. J Am Acad Nurse Pract. 2005;17(11):446-450. 20. Budd GM, Falkenstein K. Bariatric surgery: putting the squeeze on obesity. Nurse Pract. 2009;34(7):39-45. 21. Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complications after bariatric surgery and their treatment. J Parenter Enter Nutr. 2011;35(5 suppl):52S-59S. 22. Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J, Still C. Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95(11):4823-4843. 23. Kubik JF, Gill RS, Laffin M, Karmali S. The impact of bariatric surgery on psychological health. J Obes. 2013;2013:837989. http://dx.doi.org/10.1155/ 2013/837989. 24. Wadden TA, Sarwer DB, Fabricatore AN, Jones L, Stack R, Williams NS. Psychosocial and behavioral status of patients undergoing bariatric surgery: what to expect before and after surgery. Med Clin N Am. 2007;91(3):451-469. 25. Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg. 2010;20(3):349-356. 26. Lier HØ, Biringer E, Stubhaug B, Tangen T. The impact of preoperative counseling on postoperative treatment adherence in bariatric surgery patients: a randomized controlled trial. Patient Educ Couns. 2012;87(3):336-342. 27. Peacock JC, Zizzi SJ. An assessment of patient behavioral requirements preand post-surgery at accredited weight loss surgical centers. Obes Surg. 2011;21(12):1950-1957.

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28. Fogger SA, McGuinness TM. The relationship between addictions and bariatric surgery for nurses in recovery. Perspect Psychiatr Care. 2012;48(1):10-15. 29. Heinberg LJ, Ashton K, Coughlin J. Alcohol and bariatric surgery: review and suggested recommendations for assessment and management. Surg Obes Relat Dis. 2012;8(3):357-363. 30. Conason A, Teixeira J, Hsu C-H, Puma L, Knafo D, Geliebter A. Substance use following bariatric weight loss surgery. JAMA Surg. 2013;148(2):145-150. http://dx.doi.org/10.1001/2013.jamasurg.265. 31. King WC, Bond DS. The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc Sport Sci Rev. 2013;41(1):26-35. 32. Thomas CM, Morritt Taub L-F. Monitoring for and preventing the long-term sequelae of bariatric surgery. J Am Acad Nurse Pract. 2011;23(9):449-458.

Both authors are affiliated with the University of Manitoba in Winnipeg, Canada. Twyla Goritz, RN, BSN, NP, is a family nurse practitioner at Access Winnipeg West in Winnipeg, Manitoba. She has also been a clinical resource nurse at the Centre for Metabolic and Bariatric Surgery in Manitoba, Canada, and can be reached at [email protected]. Elsie Duff, NP, MEd, PhD(c), is a Senior Instructor in the Faculty of Health Sciences. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/14/$ see front matter © 2014 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2014.07.035

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