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2: PUBLIC HEALTH GUIDELINES
Balloon
FIGURE 2.2 Intragastric
balloon.
Source: Reproduced from Cash,
J. C., & Glass, C. A. (2019).
Adult-gerontology practice guidelines
(2nd ed.). Springer Publishing
Company.
FIGURE 2.3 Sleeve bypass
procedure with stomach
resection.
Source: Reproduced from Cash, J. C., &
Glass, C. A. (2019). Adult-gerontology
practice guidelines (2nd ed.). Springer
Publishing Company.
INCIDENCE
A. The Centers for Disease Control and Prevention (CDC)
notes that obesity now affects one in ve children and adolescents in the United States. According to the 2015 to 2016
National Health and Nutrition Examination Survey, the prevalence of obesity is 39%; among adults aged 40–59 years, the
prevalence is higher (42.8%).
B. The American Society for Metabolic and Bariatric Surgery
(ASMBS) reports an estimated 208,000 weight-loss operations
were performed in 2017. About 90% of surgical weight-loss
procedures are performed laparoscopically now. The most
common procedures performed today are gastric bypass, GS,
adjustable gastric band, and biliopancreatic diversion with
duodenal switch (BPD/DS). The intragastric balloons were
Food and Drug Administration-approved in 2015; only about
2.75% were done in 2017.
C. The ASMBS pediatric committee best-practice guidelines
recommend the selection criteria for adolescents being considered for a bariatric procedure should include a body
mass index (BMI) of ≥35 kg/m2 with major comorbidities (e.g., type 2 diabetes, moderate to severe sleep apnea
[apnea-hypopnea index >15], pseudotumor cerebri, or
severe nonalcoholic steatohepatitis) or a BMI of ≥40 kg/m2
with other comorbidities (e.g., hypertension, insulin resistance, glucose intolerance, substantially impaired quality of
life or activities of daily living [ADLs], dyslipidemia, sleep
apnea with apnea–hypopnea index >5). The associated
risk/benet analysis should also include consideration of
the potential long-term health risks of untreated or inadequately treated obesity for the individual candidate.
PATHOGENESIS
A. The pathogenesis of obesity is reviewed under the
“Obesity” section in this chapter. Signicant improvements in
the safety of surgical weight-loss procedures in recent years
result from improved surgical techniques, accreditation, and
use of laparoscopy. The overall mortality rate is about 0.5%.
The incidence of complications varies by surgical procedure.
Postoperative complications may occur immediately or may
occur many years after surgery. Nutritional deciencies are by
far the most common long-term complication.
PREDISPOSING FACTORS
A. Higher BMI.
B. Noncompliance with bariatric diet and exercise.
C. Lack of follow-up with healthcare professionals.
A
FIGURE 2.4 Roux-en-Y
gastric bypass.
(A) Malabsorption
procedure to assist in
weight loss: Example
of portions of the
stomach and/or small
intestine removed.
(B) Malabsorption
D. Obesity-related health problems:
1. Obstructive sleep apnea.
2. Diabetes.
3. Arthritis.
4. Hypertension.
5. Gastroesophageal reux disease.
6. Nonalcoholic fatty liver disease and nonalcoholic
steatohepatitis.
7. Pseudotumor cerebri.
8. Depression.
E. Complexity and type of surgery.
procedure: Rerouting of
the digestive tract.
Source: Reproduced from Cash,
J. C., & Glass, C. A. (2019).
Adult-gerontology practice
B
guidelines (2nd ed.). Springer
Publishing Company.
COMMON COMPLAINTS
A. Functional and nutritional:
1. Dumping syndrome usually occurs within 30 minutes
of eating high-fat/high-sugar foods and involves ushing,
sweating, lightheadedness, tachycardia, palpitations, nausea, diarrhea, and cramping.
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29
2. Hypoglycemia occurs 1 to 3 hours after eating high-carb
meals and involves shakiness, anxiety, sweating, chills,
clamminess, confusion, rapid heart rate, dizziness, hunger,
and nausea.
3. New or exacerbated reux is more common with a GS.
4. Vitamin deciencies or toxicities. Refer to Table 2.4.
a. Most common:
i. Iron deciency: fatigue, lethargy, pica, food
cravings.
ii. Iron toxicity: gastrointestinal irritation, nausea,
vomiting, indigestion, constipation, diarrhea.
iii. Protein deciency: weakness, decreased muscle
mass, brittle hair, generalized edema.
iv. Folate deciency: fatigue, palpitations, sore
tongue, diarrhea, restless legs.
v. Calcium deciency: usually silent,
hyperpara thyroidism.
vi. Calcium toxicity: constipation, nausea, vomit-
ing, dry mouth, loss of appetite.
vii. Vitamin D deciency: spasms/twitching of
eyes, burning in mouth, sweating, weakness.
viii. Vitamin B
deciency: fatigue, burning lips/
12
mouth, rapid heart rate, palpitations, sore tongue,
weakness, mood changes, neurologic changes.
b. Less common:
i. Thiamine (B
) deciency: usually in the rst
1
3 months postoperatively, often a result of vomiting, blurred or double vision, difculty swallowing,
rapid heart rate, fatigue, confusion, memory loss,
burning feet, leg weakness, amnesia.
ii. Zinc deciency: loss of smell, diminished sense
of taste, poor wound healing, skin rashes or roughness, hair loss, poor appetite, lethargy, grooved or
deformed nails, canker sores.
iii. Magnesium deciency: hyperexcitability,
cramps, tremors, fasciculation, spasms, fatigue, loss
of appetite, apathy, confusion, insomnia, irritability,
poor memory.
TABLE 2.4 MOST COMMON NUTRIENT DEFICIENCIES
Nutrient Protein Iron Folate Calcium Vitamin B
Assay Serum albumin
<3.5 mg/dL
May also need
prealbumin
and serum
creatinine
levels
Iron saturation
<10%
Serum ferritin
<10 ng/mL or
iron saturation
<7%
regardless of
ferritin value
Serum folic acid Total and ionized
calcium
Phosphorus
24-hour urinary
calcium excretion
Intact serum
parathyroid
hormone
Bone density
Serum B12 level
May also need
methylmalonic
acid level
12
Vitamin D
25 (OH)D3
<30 ng/mL
Incidence 18%–25% after
Complications
and
symptoms
Recommended
daily
amount for
prevention
Treatment
dosing
25 (OH)D3, 25-hydroxy vitamin D3
malabsorptive
procedures
Anemia
Edema
Alopecia
Asthenia
(weakness,
decreased
muscle mass,
brittle hair,
generalized
edema)
1.1–1.5 g/kg
ideal body
weight/d
10%–35% of
total energy
intake should
be from
protein
If previous
options are
not effective,
may need
parenteral
nutrition
6%–50% 1%–10% 10%–25% 5%–25% Up to 63%
Microcytic,
hypochromic
anemia
(pallor, fatigue,
poor capillary
refill,
palpitations,
pica, brittle
hair)
45–60
mg/d from
multivitamins
and iron
supplements
for
malabsorptive
procedures
Menstruating
females may
need more
150–200 mg of
elemental iron
BID, preferably
with vitamin C
Megaloblastic
or macrocytic
anemia
(palpitations,
fatigue,
diarrhea,
smooth and
sore tongue)
Neural tube
defects
May aggravate
B12 deficiency
400 mcg/d 1,200–1,500 mg/d
1,000 mcg/d
for 3 months
Secondary hyperpara
thyroidism
Enhanced bone loss
Metabolic bone
disease
(tetany, tingling,
cramping)
of calcium citrate
from food and
supplements
2,000 mg/d with
adequate vitamin D
supplementation
Megaloblastic
anemia with
macrocytosis
Neuropathy
Cognitive dysfunction
(glossitis,
constipation,
diarrhea,
neurologic
changes,
depression,
dementia)
500 mcg/d oral for
band
1,000 mcg/d oral
for malabsorptive
procedures;
may need 500–
1,000 mcg/mo
intramuscular
Depends on the level
of deficiency
Recheck levels after
3–6 months of
repletion
Myopathy
Secondary
hypocalcemia
At least 3,000 IU
of oral D3 daily,
better to titrate
to therapeutic
level
6,000–10,000
IU/d or 50,000
IU/wk up to
50,000 IU/d
Recheck level
every 3 months
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2: PUBLIC HEALTH GUIDELINES
iv. Selenium deciency (very rare): signs of hypo-
thyroidism (selenium is necessary for conversion of
thyroxine into its active form, triiodothyronine).
v. Selenium toxicity (rare): hair loss, abnormal
nails, dermatitis, peripheral neuropathy, nausea,
diarrhea, fatigue, irritability, garlic odor of breath.
5. Surgical complications:
a. Short term:
i. Anastomotic leak: <1% to 3% with RYGB.
ii. Gastrointestinal hemorrhage, bleeding: 0.5%
to 2%.
iii. Wound infection: more common with open
approach.
iv. Thromboembolism: deep vein thrombosis
(DVT) <1%.
v. Anastomotic strictures: typically within the rst
3 months, nausea and/or vomiting.
vi. Acute distention of the distal stomach.
vii. Respiratory insufciency, pneumonia.
b. Long term:
i. Band slippage: abdominal pain, acid reux,
regurgitation, dysphagia.
ii. Band erosion: may be asymptomatic, abdomi-
nal pain, gastrointestinal bleeding, weight loss,
abdominal sepsis.
iii. Intestinal obstruction: caused by internal her-
nias, adhesions; and anastomotic stenosis: colicky
central abdominal pain, nausea, vomiting, abdominal distention, absolute constipation.
iv. Hepatobiliary complications: rapid weight loss
associated with gallstone formation.
v. Gastrointestinal bleeding: rare and usually
caused by ulceration.
vi. Marginal ulcers: abdominal pain, vomiting,
bleeding, anemia.
vii. Micronutrient deciencies.
OTHER SIGNS AND SYMPTOMS
A. Expected weight loss:
1. LAGB: initial loss of 40% to 50% of excess body weight
in 3 to 5 years. Expected maintenance <50%.
2. GS: initial loss of >50% of excess body weight in 3 to
5 years. Expected maintenance >50%.
3. RYGB: initial loss of 60% to 80% of excess body weight
in 1 year. Expected maintenance >50%.
4. BPD/DS: initial loss of 60% to 70% of excess body
weight in 1 year. Expected maintenance of 60% to 70%.
5. Intragastric balloons: loss of about 10% to 15% of body
weight is typical during the 6 months following intragastric balloon placement. Expected maintenance: The gastric
balloon is only placed for 6 months then removed.
B. Weight regain of up to 20 lbs is common after 2 years.
C. Constipation and/or diarrhea may occur, depending on
the procedure.
D. Weight loss of <25% of excess body weight is considered a
surgical failure and may be revised.
E. Even if weight loss is adequate, clients may express disap-
pointment and/or depression related to the rate or amount of
weight lost.
F. Nausea and vomiting after LAGB may indicate need for
band adjustment.
SUBJECTIVE DATA
A. Review the onset and duration of symptoms.
B. Elicit the date of surgery, type of surgery, and any reopera-
tions or complications.
C. Review previous highest weight and amount of excess
weight lost since surgery.
D. Evaluate the location and level of pain/discomfort.
E. Evaluate the overall psychosocial changes since surgery.
F. Review a 24-hour food recall, choices of healthy foods,
skipping meals, food aversion (e.g., red meat), serving size,
and intolerance.
G. Review medications and supplement use.
PHYSICAL EXAMINATION
A. Check height, weight, waist, and hip circumference.
Calculate BMI, waist-to-hip ratio, pulse, respirations, and
blood pressure. Check temperature if infection is suspected.
B. Inspect:
1. Examine the skin, evaluate surgical site(s), and evalu-
ate redness and tenderness.
2. Perform oral/dental examination.
3. Evaluate for dehydration.
4. Perform eye examination: Evaluate eye movement (thi-
amine deciency).
5. Evaluate gait.
6. Obtain general overview of personal presence and
affect.
C. Auscultate:
1. Auscultate the heart and lungs.
2. Auscultate the abdomen for bowel sounds.
D. Palpate:
1. Evaluate the abdomen for presence of tenderness.
2. Evaluate the abdomen for masses.
E. Perform neurologic examination:
1. Perform neurologic examination, including checking
deep tendon reexes (DTRs), sense of smell, and Babinski
reex (vitamin B
deciency).
12
DIAGNOSTIC TESTS
A. Laboratory testing is recommended annually for all proce-
dures. Refer to Table 2.5.
1. Complete blood count with differential.
2. Liver function tests.
3. Glucose.
4. Creatinine.
5. Electrolytes.
B. Annual laboratory testing suggested for LAGB; recom-
mended for all other procedures:
1. Iron/ferritin.
2. Vitamin B
.
12
3. Folate.
4. Calcium.
5. Intact parathyroid hormone (PTH).
6. 25-hydroxy vitamin D.
7. Albumin/prealbumin.
C. Optional labs that may be required based on symptoms:
1. Zinc.
2. Copper.
3. Vitamin B
4. Vitamin B
.
1
.
6
5. Vitamin A.
D. Other labs as appropriate for the condition and prevention:
1. Monitor hemoglobin A1c and blood glucose closely in
clients with diabetes. Diabetes has resolved after bariatric
surgery in some clients.
2. Obtain lipid prole.
POSTBARIATRIC SURGERY LONG-TERM FOLLOW-UP
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TABLE 2.5 RECOMMENDED ANNUAL LABORATORY MONITORING FOR BYPASS CLIENTS
Gastric Band Gastric Sleeve Gastric Bypass BPD/DS
Complete blood count X X X X
Liver function tests X X X X
Glucose X X X X
Creatinine X X X X
Electrolytes X X X X
Iron/ferritin Suggested X X X
31
Vitamin B
Folate Suggested X X X
Calcium Suggested X X X
Intact PTH Suggested X X X
Vitamin D 25-OH Suggested X X X
Albumin/prealbumin Suggested X X X
Bone mineral density X X X
Zinc Optional Optional Optional
Vitamin B
Vitamin A Optional 24 months and beyond Optional 24 months and beyond Optional 24 months and beyond
BPD/DS, biliopancreatic diversion with duodenal switch; PTH, parathyroid hormone; 25-OH, 25-hydroxy Vitamin D3.
Source: Adapted from Heber, D., Greenway, F. L., Kaplan, L. M., Livingston, E., Salvador, J., Still, C., & Endocrine Society. (2010). Endocrine and nutritional management
of the post-bariatric surgery client: An endocrine society clinical practice guideline. Endocrine Society, 95(11), 4823–4843. https://doi.org/10.1210/jc.2009-2128; Data
from Becker, D. A., Balcer, L. J., & Galetta, S. L. (2012). The neurological complications of nutritional deficiency following bariatric surgery. Journal of Obesity, 2012, 1–8. h
ttps://doi.org/10.1155/2012/608534; Handzlik-Orlik, G., Holecki, M., Orlik, B., Wylezol, M., & Dulawa, J. (2015). Nutrition management of the post-bariatric surgery
client. Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition, 30(3), 383–392. https://doi.org/10.1177/08845336
14564995; and Kerner (2014).
E. Abdominal ultrasound.
F. CT scan of the abdomen.
G. Doppler ultrasound of the limb for suspected DVT.
H. Pulmonary ventilation/perfusion scan for suspected pul-
12
1
monary embolus.
I. Bone mineral density (dual-energy x-ray absorptiometry
[DEXA]) scan: recommended annually until stable after malabsorptive procedures.
J. Endoscopy as needed for abdominal complaints.
Suggested X X X
Optional Optional Optional
P. Malnutrition/protein deciency.
Q. Incisional hernia.
R. Osteoporosis.
PLAN
A. General interventions:
1. Lifelong follow-up is required after bariatric surgery.
Ideally, clients should follow up with their surgical group,
but many do not. Primary care providers are well-positioned
to capture those lost to follow-up. Continuous reinforce-
DIFFERENTIAL DIAGNOSES
A. Postoperative surgical complication(s).
B. Infection.
C. Abdominal pain.
D. Fascial dehiscence.
E. DVT.
F. Bowel obstruction.
G. Band slippage.
H. Anastomosis leakage.
I. Stomal stenosis/stricture.
J. Cholecystitis.
K. Dumping syndrome.
L. Food intolerance.
M. Gastric ulcer.
N. Gastroenteritis.
O. Vitamin deciency.
ment of good nutritional habits is important.
B. Client teaching:
1. Many complications can be prevented by adhering to
diet and lifestyle recommendations.
2. Supplements are required lifelong; strict adherence
will prevent deciencies.
3. Dumping syndrome can be prevented by avoiding
foods that trigger it, such as high-sugar and/or high-fat
foods. Clients can keep food diaries to identify triggers.
4. Hypoglycemia can usually be prevented by careful
monitoring of carbohydrate intake.
5. Surgery does not replace the need for a balanced diet or
exercise. Approximately 150 minutes of moderate activity
each week is recommended, although safety and tolerance
differ, so exercise recommendations should be individualized. Any activity is better than none.
32
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2: PUBLIC HEALTH GUIDELINES
6. Food should be chewed thoroughly and consumed
slowly. Liquids should be avoided 30 minutes before
and after meals. Avoid eating and drinking liquids
simultaneously.
7. Protein is important for maintaining muscle mass
during rapid weight loss and avoiding hunger during
maintenance. Between 60 and 100 g of protein daily is recommended. Limit carbohydrate intake to 50 g/d or less.
Limiting carbohydrate intake reduces risk of weight regain
by preventing rebound hunger.
8. To prevent dehydration as well as reduce the risk of
kidney stones and constipation, encourage clients to drink
64 oz of uids daily.
9. Stress, boredom, and emotions often affect eating habits.
Identifying problems and seeking help early are important.
10. Support groups can be a vital source of education and
social support, both of which are key to weight loss and
maintenance.
11. Weight plateaus are common and normal. They are the
body’s way of trying to establish a new set point. Do not be
discouraged by plateaus. Consistency is key to overcoming them.
12. Adequate sleep and successful stress management are
also key to successful weight loss and maintenance.
C. Pharmaceutical therapy:
1. Medication absorption can be altered after bariat-
ric surgery. Evaluate need for adjustments of medication
dosing, especially diabetic, psychiatric, and antihypertensive medications, as well as any medication with a narrow
therapeutic window.
Drugs with a small therapeutic window such as digoxin, carbamazepine, theophylline, and phenytoin should be crushed due to the increase
in toxicity.
2. Clients may require alternate formulations of medi-
cations, including crushed, chewable, liquid, patches,
intramuscular (IM), or subcutaneous. Long-acting (LA),
extended release, or enteric coated medications may
not be absorbed as well and may need to be switched to
immediate release. Medications designed to release slowly
should not be crushed or chewed since the full dose will be
released faster than expected.
3. Recommended supplementations:
a. Multivitamin plus mineral supplements contain-
ing iron, folic acid, zinc, copper, selenium, and thiamin
(200% of RDA):
i. LAGB: once daily.
ii. All other procedures: twice daily.
b. Calcium (all procedures):
i. 1,200 to 1,500 mg daily from food and calcium
citrate in divided doses.
c. Vitamin D (all procedures):
i. 3,000 IU daily (as ergocalciferol [vitamin D
cholecalciferol [vitamin D3]), titrate to reach normal
concentrations of 30 ng/mL.
ii. Treatment for deciency: 50,000 IU vitamin D
or D3 once per week for 8 weeks, followed by maintenance therapy of 1,500 to 2,000 IU/d to achieve
normal concentrations.
d. Iron:
i. LAGB: not usually necessary unless iron intake
from food is insufcient.
ii. All other procedures: 45 to 60 mg elemental daily
from multivitamin plus additional supplementation.
], or
2
iii. Treatment for deciency: 150 to 200 mg/d ele-
mental supplement.
e. Vitamin B
i. LAGB: not usually necessary.
ii. All other procedures: 250 to 350 mcg/d or 1,000
(cobalamin):
12
mcg/mo IM or 3,000 mcg every 6 months IM after
RYGB and BPD.
iii. Treatment for deciency: 1,000 to 2,000 mcg/d
sublingual.
f. Thiamin (all procedures):
i. Should be included in the routine multivitamin
supplement.
ii. Treatment for deciency: 500 mg thiamin/d
intravenously (IV) for 3 to 5 days, then 250 mg/d
for 3 to 5 days or until the symptoms disappear, and
then further treatment by oral administration of 100
mg/d as needed.
g. Folate (folic acid; all procedures):
i. 400 mcg/d should be included in the routine mul-
tivitamin; pregnant individuals or those planning to
conceive should take 800 to 1,000 mcg/d folic acid
included in a multivitamin supplement or separately.
ii. Treatment for deciency: 1,000 mcg/d folic
acid.
h. Fat-soluble vitamins (A, K, and E):
i. 6,000 IU vitamin A should be included in the
routine multivitamin; for pregnant individuals or
those planning to conceive, the beta carotene form
of vitamin A is preferred over retinol.
ii. After BPD: 10,000 IU/d vitamin A, 300 mcg/d
vitamin K, and 400 IU/d vitamin E (included in a
multivitamin or separately):
1) Recommended treatment for deciency
when changes in the cornea appear: 50,000 to
100,000 IU IM for 3 days followed by 50,000
IU/d IM for 2 weeks.
iii. Treatment for deciency:
1) Vitamin A deciency without corneal
changes: 10,000 to 25,000 IU/d orally to achieve
clinical improvement.
2) Vitamin E deciency: 800 to 1,200 IU/d to
reach normal serum concentrations.
3) Vitamin K deciency: 10 mg IM or submus-
cular, followed by 1 to 2 mg/wk parenterally or
orally.
i. Zinc (Zn):
i. The routine daily multivitamin should contain
15 mg/d.
ii. 60 mg Zn BID for treatment of deciency.
j. Copper (Cu):
i. The routine daily multivitamin should contain
2 mg Cu.
ii. Severe deciency requires 2–4 mg/d Cu IV for 6
days.
k. Vitamin C:
2
i. The routine daily multivitamin should follow
the RDA recommendation for vitamin C.
ii. Treatment: 100 mg vitamin C TID or 500 mg/d
for 1 month.
4. Long-term anticoagulation may be needed for DVT/
pulmonary embolism (PE) prophylaxis.
5. Nonsteroidal anti-inammatory drugs (NSAIDs) and
corticosteroids should be avoided to reduce the risk of
marginal ulcers.
SUBSTANCE USE DISORDERS
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33
D. Psychosocial changes:
1. Bariatric surgery often results in dramatic lifestyle
and body changes and may require signicant psychosocial adjustments for the client as well as their friends and
family.
a. Monitor for depression/anxiety, body image con-
cerns, and social support.
b. Alcoholism can be a concern after bariatric surgery.
Less alcohol is needed to elevate blood alcohol levels
and blood alcohol levels are sustained longer after bariatric surgery.
FOLLOW-UP
A. Bariatric surgery requires lifelong follow-up, ideally by a
multidisciplinary team of healthcare providers. Initial follow-up
schedules are set by the surgeon. Long-term follow-up (after
the rst 2 years) is usually provided for by the bariatric surgery
program, but research has shown that follow-up is often poor,
which leads to poor outcomes and substandard client care.
B. Laboratory and diagnostic testing is required as listed in
Table 2.5. Early recognition of nutritional deciencies can prevent permanent damage and even death.
C. Chronic disease management (particularly diabetes, lip-
ids, and bone disease) can be simpler or more complex after
bariatric surgery, depending on the client’s adherence to lifestyle and nutritional recommendations.
CONSULTATION/REFERRAL
A. Bariatric surgeon for surgical complications and revisions.
B. Surgeon for cholecystectomy (preferably bariatric surgeon
or general/gastrointestinal surgeon experienced in the care of
bariatric clients).
C. Gastroenterology consult.
D. Nutrition consultation and/or counseling.
E. Psychologist consultation.
F. Physical therapy/exercise specialist.
G. Support group.
American Society for Metabolic and Bariatric Surgery. (n.d). Life after bar-
iatric surgery. https://asmbs.org/patients/life-after-bariatric-surgery
American Society for Metabolic and Bariatric Surgery. (2016, March).
Endorsed procedures and devices. https://asmbs.org/resources/
endorsed-procedures-and-devices?/resources/approved-procedures
American Society for Metabolic and Bariatric Surgery. (2018, June).
Estimates of bariatric surgery numbers, 2011–2017. https://asmbs.org/re
sources/estimate-of-bariatric-surgery-numbers
Becker, D. A., Balcer, L. J., & Galetta, S. L. (2012). The neurological compli-
cations of nutritional deciency following bariatric surgery. Journal of
Obesity, 2012, 1–8. https://doi.org/10.1155/2012/608534
Dagan, S. S., Goldenshluger, A., Globus, I., Schweiger, C., Kessler, Y.,
Sandbank, G. K., Ben-Porat, T., & Sinai, T. (2017). Nutritional recommendations for adult bariatric surgery patients: Clinical practice.
Advances in Nutrition, 8(2), 382–394. https://doi.org/10-3945/an.116
.014258
Handzlik-Orlik, G., Holecki, M., Orlik, B., Wylezol, M., & Dulawa, J.
(2015). Nutrition management of the post-bariatric surgery client.
Nutrition in Clinical Practice: Ofcial Publication of the American Society
for Parenteral and Enteral Nutrition, 30(3), 383–392. https://doi.org/10.
1177/0884533614564995
Hamdan, K., Somers, S., & Chand, M. (2011). Management of late post-
operative complications of bariatric surgery. British Journal of Surgery,
98(10), 1345–1355. https://doi.org/10.1002/bjs.7568
Heber, D., Greenway, F. L., Kaplan, L. M., Livingston, E., Salvador, J., Still,
C., & Endocrine, Society. (2010). Endocrine and nutritional management of the post-bariatric surgery client: An endocrine society clinical practice guideline. Endocrine Society, 95(11), 4823–4843. https://
doi.org/10.1210/jc.2009-2128
Iannelli, A., Dainese, R., Piche, T., facchiano, E., & Gugenhein, J. (2008).
Laparoscopic sleep gastrectomy for morbid obesity. World Journal of
Gastroenterology, 14, 821–827. https://doi.org/10.3748/wjg.14.821
Parrott, J., Frank, L., Rabena, R., Craggs-Dino, L., Isom, K. A., & Greiman,
L. (2017). American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient
2016 update: Micronutrients. Surgery for Obesity and Related Diseases,
13(5), 727–741. https://doi.org/10.1016/j.soard.2016.12.018
Pounds, B. P. (2015). Improving primary care provider knowledge regard-
ing malabsorptive nutritional deciencies after bariatric surgery. Frontier
Nursing University. Unpublished manuscript
University of California, San Francisco, UCSF Health. (n.d). Dietary guide-
lines after bariatric surgery. https://www.ucsfhealth.org/education/di
etary_guidelines_after_gastric_bypass/index.html
INDIVIDUAL CONSIDERATIONS
A. Females:
1. All individuals of childbearing age should receive ade-
quate folate supplementation and be given contraception
and preconception counseling.
2. Oral contraceptives (OCPs) may not be as effective
after bariatric surgery due to changes in absorption.
B. Pregnancy:
1. Pregnancy should be delayed for 12 to 18 months after
bariatric surgery or however long it takes for weight loss
to stabilize.
2. Bariatric surgeon consult may be required.
3. Increased folic acid may be needed preconception to
reduce the risk of neural tube defects.
4. Increased vitamin supplementation may be necessary
during pregnancy. Vitamin A should be limited to 5,000 IU
daily.
5. Gastric band may need to be adjusted during pregnancy.
6. Serial ultrasounds may need to be done to follow fetal
growth.
BIBLIOGRAPHY
Ali, M., Moustarah, F., & Kim, J. (2015). American society for metabolic and
bariatric surgery position statement on intra-gastric balloon therapy, Draft.
https://asmbs.org/app/uploads/2015/10/IntraGastricBalloon_Stat
ement_DRAFT.pdf
SUBSTANCE USE DISORDERS
DEFINITION
A. Alcoholism and drug dependence and addiction, known as
substance use disorders (SUDs), are complex problems. Most
scientists and medical researchers now consider dependence on
alcohol or drugs to be a long-term illness, like asthma, hypertension (high blood pressure), or diabetes. Most people who drink
alcohol drink very little, and many people can stop taking drugs
without a struggle. However, some people develop an SUD—
use of alcohol or drugs that is compulsive or dangerous (or both).
B. The National Survey on Drug Use and Health (NSDUH)
states misuse of prescription drugs is dened as use in any
way not directed by a doctor, including use without a prescription of one's own; use in greater amounts, more often, or
longer than told to take a drug; or use in any other way not
directed by a doctor:
1. The National Institute on Drug Abuse (NIDA) notes
many misused drugs can alter a person’s thinking and
judgment, leading to health risks, including addiction, drugged driving, infectious disease, and potential harm to babies with prenatal exposure. Table 2.6
shows the NIDA’s list of commonly abused substances.
Table 2.7 shows a list of commonly abused prescription
medications.
34
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2: PUBLIC HEALTH GUIDELINES
TABLE 2.6 NATIONAL INSTITUTE ON DRUG ABUSE LIST OF COMMONLY ABUSED DRUGS
Substances:
Category and
Name
Examples of Commercial and
Street Names
DEA Schedulea/
Drug
Administration
b
Acute Effects/Health Risks
Tobacco Increased blood pressure and heart rate/chronic lung
disease; cardiovascular disease; stroke; cancers of
Nicotine Found in cigarettes, cigars, bidis,
hookahs, and smokeless tobacco (snuff,
spit tobacco, chew)
Not scheduled/
smoked, snorted,
chewed, vaporized
the mouth, pharynx, larynx, esophagus, stomach,
pancreas, cervix, kidney, bladder, and acute
myeloid leukemia; adverse pregnancy outcomes;
addiction
Alcohol In low doses, euphoria, mild stimulation, relaxation,
lowered inhibitions; in higher doses, drowsiness,
Alcohol (ethyl
alcohol)
Found in liquor, beer, and wine Not scheduled/
swallowed
slurred speech, nausea, emotional volatility, loss of
coordination, visual distortions, impaired memory,
sexual dysfunction, loss of consciousness/increased
risk of injuries, violence, fetal damage (in pregnant
individuals); depression; neurologic deficits;
hypertension; liver and heart disease; addiction;
fatal overdose
Cannabinoids Euphoria; relaxation; slowed reaction time; distorted
sensory perception; impaired balance and
Marijuana Blunt, dope, ganja, grass, herb, joint,
bud, Mary Jane, pot, reefer, green,
trees, smoke, sinsemilla, skunk, weed
I/smoked, swallowed
coordination; increased heart rate and appetite;
impaired learning, memory; anxiety; panic attacks;
psychosis/cough; frequent respiratory infections;
possible mental health decline; addiction
Hashish Boom, gangster, hash, hash oil, hemp I/smoked, swallowed
Opioids Euphoria; drowsiness; impaired coordination;
dizziness; confusion; nausea; sedation; feeling
Heroin Diacetylmorphine: smack, horse, brown
sugar, dope, H, junk, skag, skunk,
white horse, China white, cheese (with
I/injected, smoked,
snorted
of heaviness in the body; slowed or arrested
breathing; constipation; endocarditis; hepatitis; HIV;
addiction; fatal overdose
OTC cold medicine and antihistamine)
Opium Laudanum, paregoric: big O, black stuff,
block, gum, hop
II, III, V/swallowed,
smoked
Stimulants Increased heart rate, blood pressure, body
temperature, metabolism; feelings of exhilaration;
Cocaine Cocaine hydrochloride: blow, bump,
C, candy, Charlie, coke, crack, flake,
rock, snow, toot
II/snorted, smoked,
injected
increased energy, mental alertness; tremors;
reduced appetite; weight loss; irritability; anxiety;
panic; paranoia; violent behavior; psychosis;
insomnia; cardiac or cardiovascular complications;
Amphetamine Biphetamine, dexedrine: bennies,
black beauties, crosses, hearts, LA
turnaround speed, truck drivers, uppers
Methamphetamine Desoxyn: meth, ice, crank, chalk, crystal,
fire, glass, go fast, speed
II/swallowed, snorted,
smoked, injected
II/swallowed, snorted,
smoked, injected
stroke; seizures; addiction
Also, for cocaine: nasal damage from snorting
Also, for methamphetamine: severe dental problems
Club Drugs MDMA: mild hallucinogenic effects; increased tactile
sensitivity, empathic feelings; lowered inhibition;
MDMA Ecstasy, Adam, clarity, Eve, lover’s speed,
peace, uppers
I/swallowed, snorted,
injected
anxiety; chills; sweating; teeth clenching; muscle
cramping/sleep disturbances; depression; impaired
memory; hyperthermia; addiction
Flunitrazepam Rohypnol: forget-me pill, Mexican Valium,
R2, roach, Roche, roofies, roofinol,
rope, rophies
c
GHB
Gamma-hydroxybutyrate: G, Georgia
home boy, grievous bodily harm, liquid
IV/swallowed, snorted
I/swallowed
Flunitrazepam: sedation; muscle relaxation; confusion;
memory loss; dizziness; impaired coordination/
addiction
GHB: drowsiness; nausea; headache; disorientation;
loss of coordination; memory loss/unconsciousness;
seizures; coma
ecstasy, soap, scoop, goop, liquid X
(continued)
SUBSTANCE USE DISORDERS
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TABLE 2.6 NATIONAL INSTITUTE ON DRUG ABUSE LIST OF COMMONLY ABUSED DRUGS (CONTINUED)
35
Substances:
Category and
Name
Examples of Commercial and
Street Names
DEA Schedulea/
Drug
Administration
b
Acute Effects/Health Risks
Dissociative Drugs Feelings of being separate from one’s body and
environment; impaired motor function/anxiety;
Ketamine Ketalar SV: cat Valium, K, special K,
vitamin K
III/injected, snorted,
smoked
tremors; numbness; memory loss; nausea
Also for ketamine: analgesia; impaired memory;
delirium; respiratory depression and arrest; death
PCP and analogs Phencyclidine: angel dust, boat, hog,
love boat, peace pill
I, II/swallowed,
smoked, injected
Also for PCP and analogs: analgesia; psychosis;
aggression; violence; slurred speech; loss of
coordination; hallucinations
Salvia divinorum Salvia, shepherdess’s herb, Maria
Pastora, magic mint, Sally-D
Not scheduled/
chewed, swallowed,
Also for DXM: euphoria; slurred speech; confusion;
dizziness; distorted visual perceptions
smoked
DXM Found in some cough and cold
medications: robotripping, robo, triple
Not scheduled/
swallowed
C
Hallucinogens Altered states of perception and feeling;
hallucinations; nausea
LSD Acid, blotter, cubes, microdot, yellow
sunshine, blue heaven
I/swallowed,
absorbed through
mouth tissues
Also for LSD and mescaline: increased body
temperature, heart rate, blood pressure; loss of
appetite; sweating; sleeplessness; numbness;
dizziness; weakness; tremors; impulsive behavior;
Mescaline Buttons, cactus, mesc, peyote I/swallowed, smoked
rapid shifts in emotion
Also for LSD: flashbacks, hallucinogen persisting
Psilocybin Magic mushrooms, purple passion,
shrooms, little smoke
I/swallowed
perception disorder
Also for psilocybin: nervousness; paranoia; panic
Other Compounds Steroids: no intoxicating effects; blood clotting and
cholesterol changes; liver cysts; hostility and
Anabolic steroids Anadrol, Oxandrin, Durabolin,
Depo-Testosterone, Equipoise, roids,
juice, gym candy, pumpers
III/injected,
swallowed, applied
to skin
aggression; acne; in adolescents: premature
stoppage of growth; in males: prostate cancer,
reduced sperm production, shrunken testicles, breast
enlargement; in females: menstrual irregularities,
Inhalants Solvents (paint thinners, gasoline,
glues); gases (butane, propane,
aerosol propellants, nitrous oxide);
nitrites (isoamyl, isobutyl, cyclohexyl):
laughing gas, poppers, snappers,
whippets
Not scheduled/inhaled
through nose or
mouth
development of beard and other masculine
characteristics
Inhalants (varies by chemical): stimulation; loss of
inhibition; headache; nausea or vomiting; slurred
speech; loss of motor coordination; wheezing/
cramps; muscle weakness; depression; memory
impairment; damage to cardiovascular and nervous
systems; unconsciousness; sudden death
Prescription Medications
CNS depressants For more information on prescription medications, please visit
www.nida.nih.gov/DrugPages/PrescripDrugsChart.html.
Stimulants
Opioid pain
relievers
a
Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I
drugs are available for research only and have no approved medical use; Schedule II drugs are available only by prescription (unrefillable) and require a form for ordering.
Schedule III and IV drugs are available by prescription, may have five refills in 6 months, and may be ordered orally. Some Schedule V drugs are available OTC.
b
Some of the health risks are directly related to the route of drug administration. For example, injection drug use can increases the risk of infection through needle
contamination with staphylococci, HIV, hepatitis, and other organisms.
c
Associated with sexual assaults.
CNS, central nervous system; DEA, Drug Enforcement Administration; DXM, dextromethorphan; GHB, gamma-hydroxybutyric acid; LSD, lysergic acid diethylamide; MDMA,
methylenedioxymethamphetamine; OTC, over the counter; PCP, phencyclidine.
ID:c0002-p5370ID:c0002-p5365ID:c0002-p5365
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36
2: PUBLIC HEALTH GUIDELINES
TABLE 2.7 NATIONAL INSTITUTE ON DRUG ABUSE LIST OF COMMONLY ABUSED PRESCRIPTION DRUGS
Substances:
Category and
Name
Examples of Commercial and Street
Names
Depressants Sedation/drowsiness; reduced anxiety; feelings
Barbiturates Amytal, Nembutal, Seconal, phenobarbital:
barbs, reds, red birds, phennies, tooies,
yellows, yellow jackets
Benzodiazepines Ativan, Halcion, Librium, Valium, Xanax,
Klonopin: candy, downers, sleeping pills, tranks
Sleep medications Ambien (zolpidem), Sonata (zaleplon), Lunesta
(eszopiclone)
Opioids and Morphine Derivatives
b
Codeine Empirin with codeine, Fiorinal with codeine,
Robitussin A-C, Tylenol with codeine: Captain
Cody, Cody, schoolboy (with glutethimide:
doors and fours, loads, pancakes and syrup)
Morphine Roxanol, Duramorph: M, Miss Emma, monkey,
white stuff
Methadone Methadone, Dolophine: fizzies, amidone (with
MDMA: chocolate chip cookies)
Fentanyl and
analogs
Actiq, Duragesic, Sublimaze: Apache, China
girl, dance fever, friend, good-fella, jackpot,
murder 8, TNT, Tango and Cash
Other opioid
pain relievers:
oxycodone HCL,
hydrocodone
bitartrate,
hydromorphone,
oxymorphone,
meperidine,
propoxyphene
Tylox, OxyContin, Percodan, Percocet: oxy,
O.C., OxyContin, Oxycet, hillbilly heroin,
percs
Vicodin, Lortab, Lorcet: vike, Watson-387
Dilaudid: juice, smack, D, footballs, dillies
Opana, Numorphan, Numorphone: biscuits,
blue heaven, blues, Mrs. O, octagons, stop
signs, O bomb
Demerol, meperidine hydrochloride: demmies,
painkiller
Darvon, Darvocet
DEA Schedulea/
Drug
Administration Intoxication Effects/Health Risks
of well-being; lowered inhibitions; slurred
II, III, IV/injected,
swallowed
speech; poor concentration; confusion;
dizziness; impaired coordination and memory/
slowed pulse; lowered blood pressure; slowed
breathing; tolerance; withdrawal; addiction;
IV/swallowed
increased risk of respiratory distress and death
when combined with alcohol
For barbiturates: euphoria; unusual excitement;
IV/swallowed
fever; irritability/life-threatening withdrawal in
chronic users
Pain relief; euphoria; drowsiness; sedation;
weakness; dizziness; nausea; impaired
II, III, IV/injected,
swallowed
coordination; confusion; dry mouth; itching;
sweating; clammy skin; constipation/
slowed or arrested breathing; lowered pulse
and blood pressure; tolerance; addiction;
unconsciousness; coma; death; increased
II, III/injected,
swallowed, smoked
risk of death when combined with alcohol or
other CNS depressants
For fentanyl: 80–100 times more potent
II/swallowed, injected
analgesic than morphine
For oxycodone: muscle relaxation/twice as
II/injected, smoked,
snorted
potent analgesic as morphine; high abuse
potential
For codeine: less analgesia, sedation, and
respiratory depression than morphine
II, III, IV/chewed,
swallowed,
snorted, injected,
For methadone: used to treat opioid addiction
and pain; significant risk of overdose when
used improperly
suppositories
Stimulants Feelings of exhilaration; increased energy;
Amphetamines Biphetamine, Dexedrine, Adderall: bennies,
Methylphenidate Concerta, Ritalin: JIF, MPH, R-ball, skippy, the
Other Compounds Euphoria; slurred speech/increased heart rate
DXM Found in some cough and cold medications:
a
Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I
drugs are available for research only and have no approved medical use. Schedule II drugs are available only by prescription and require a new prescription for each refill.
Schedule III and IV drugs are available by prescription, may have five refills in 6 months, and may be ordered orally. Most Schedule V drugs are available over the counter.
b
Taking drugs by injection can increase the risk of infection through needle contamination with staphylococci, HIV, hepatitis, and other organisms. Injection is a more common
practice for opioids, but risks apply to any medication taken by injection.
CNS, central nervous system; DEA, Drug Enforcement Administration; DXM, dextromethorphan; HCl, hydrochloride; MDMA, methylenedioxymethamphetamine.
Source: National Institute on Drug Abuse (NIDA): Visit NIDA at www.drugabuse.gov; National Institutes of Health (NIH); U.S. Department of Health and Human Services; The
NIH: Turning Discovery Into Health.
black beauties, crosses, hearts, LA
turnaround, speed, truck drivers, uppers
smart drug, vitamin R
robotripping, robo, triple C
II/injected,
swallowed, smoked,
snorted
II/injected,
swallowed, snorted
Not scheduled/
swallowed
mental alertness/increased heart rate, blood
pressure, and metabolism; reduced appetite;
weight loss; nervousness; insomnia; seizures;
heart attack; stroke
For amphetamines: rapid breathing; tremor,
loss of coordination; irritability; anxiousness;
restlessness/delirium; panic; paranoia;
hallucinations; impulsive behavior;
aggressiveness; tolerance; addiction
For methylphenidate: increase or decrease in
blood pressure; digestive problems; loss of
appetite; weight loss
and blood pressure; dizziness; nausea;
vomiting; confusion; paranoia; distorted
visual perceptions; impaired motor function
SUBSTANCE USE DISORDERS
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37
2. Rates of opioid overdose deaths doubled from 2010 to
2016, with the sharpest increase in deaths related to illicitly
made fentanyl and fentanyl analogs (synthetic opioids).
In response to the opioid crisis, the U.S. Surgeon General
released a public health advisory to urge more individuals,
including family, friends, and those who are personally at
risk of an opioid overdose, to keep the drug naloxone, an
opioid antagonist, on hand as a potentially lifesaving medication that can reverse the effects of an opioid overdose.
C. The NSDUH denes binge drinking for males as drink-
ing ve or more drinks on an occasion on at least 1 day in the
past 30 days and for femalesas drinking four or more drinks
on an occasion on at least 1 day in that period. Heavy alcohol
use is dened as binge drinking on 5 or more days in the past
30 days. Any alcohol use, binge drinking, and heavy drinking are not mutually exclusive categories of use: Heavy use is
included in the estimates of binge and current use, and binge
use is included in the estimates of current use.
INCIDENCE
A. Statistics indicate that the most commonly used legal sub-
stances are caffeine, alcohol, and nicotine. According to the
NIDA, tobacco use is the leading preventable cause of disease,
disability, and death in the United States.
1. According to the Centers for Disease Control and
Prevention (CDC), approximately one in ve premature
deaths in the United States every year are the result of
cigarette smoking. On average, smokers die 10 years earlier than nonsmokers. In 2017, 14.0% of all adults aged 18
years or older were current cigarette smokers.
2. According to the E-Cigarette Use Among Youth
and Young Adults 2016 Report of the Surgeon General,
e-cigarettes are now the most commonly used tobacco
product among youth in the United States:
a. These products are now the most commonly used
form of tobacco among youth in the United States, surpassing conventional tobacco products, including cigarettes, cigars, chewing tobacco, and hookahs.
b. Use of e-cigarette is strongly associated with use
of other tobacco products among youth and young
adults, including combustible tobacco products.
c. These devices are referred to, by the companies
themselves and by consumers, as “e-cigarettes,”
“e-cigs,” “cigalikes,” “e-hookahs,” “mods,” “vape
pens,” “vapes,” and “tank systems.”
d. Ingestion of e-cigarette liquids containing nicotine
can cause acute toxicity and possibly death if the contents of rell cartridges or bottles containing nicotine
are consumed.
B. Research suggests that sexual minorities (e.g., people who
identify as lesbian, gay, or bisexual) are at greater risk of substance use and mental health issues compared with the sexual majority population that identies as being heterosexual.
Although sexual orientation is not a new construct, many
federally funded surveys have only recently begun to identify sexual minorities in their data collections. In 2015, the
NSDUH added two questions on sexual orientation, one for
sexual identity and one for sexual attraction, making it the
rst nationally representative, comprehensive source of federally collected information on substance use and mental health
issues among sexual minority adults. Sexual minority adults
identied as being lesbian, gay, or bisexual. Sexual majority
adults identied as being heterosexual or straight.
C. The 2015 NSDUH obtains information on 10 categories of
illicit drugs: marijuana; cocaine in any form, including crack;
heroin; hallucinogens; inhalants; methamphetamine; and the
misuse of prescription pain relievers, tranquilizers, stimulants, and sedatives. The survey noted sexual minority adults
were more likely than sexual majority adults to have engaged
in the following in the past year:
1. Cocaine use (5.1% vs. 1.8%).
2. Heroin use (0.9% vs. 0.3%).
3. Use of hallucinogens (5.0% vs. 1.6%), including use
of lysergic acid diethylamide (LSD; 1.7% vs. 0.5%) and
ecstasy (3.2% vs. 0.9%).
4. Use of inhalants (3.7% vs. 0.3%).
5. Methamphetamine use (2.3% vs. 0.6%).
6. Misuse of prescription tranquilizers (5.9% vs. 2.2%).
7. Misuse of prescription stimulants (4.2% vs. 1.9%).
8. Misuse of prescription sedatives (1.2% vs. 0.6%).
A substance abuse problem is recognized in as few as 1 in 20
substance-abusing clients seeking medical attention.
D. The NSDUH asks respondents about their alcohol use
in the 30 days before the interview (i.e., current use). Sexual
minority adults aged 18 or older were more likely than sexual
majority adults to be current alcohol drinkers or binge drinkers in the past month. However, similar percentages of sexual minority and sexual majority adults were heavy alcohol
users in the past month. Among sexual minority adults, 63.6%
were current alcohol drinkers and 36.1% were binge alcohol
drinkers.
PATHOGENESIS
A. No single gene has been identied as the culprit in the
predisposition to substance dependence. Certain biological
features seem to be inherited by rst-degree relatives (particularly males) of alcoholics, for example, a resistance to intoxication, a subnormal cortisol rise after drinking, and a subnormal
epinephrine release following stress.
B. Some theories postulate alterations in metabolism of alco-
hol and drugs in people who are dependent. Studies pertaining to alcohol have included research into genetic heritability,
awed metabolism of alcohol by alcoholics, insensitivity to
alcohol inherited by alcoholics (thus tending to increase tolerance or ability to know when to stop), and alterations in brain
waves in alcoholics.
C. Although much of the research is specic to only one drug,
much of what is known about the research can be applied to
other drugs.
D. According to the NIDA, people begin taking drugs for a
variety of reasons, including:
1. To feel good/pleasure of “high.”
2. To feel better, for example, relieve stress, pain, sleep.
3. To do better/improve performance.
4. Curiosity/boredom.
5. Peer pressure.
E. According to the E-Cigarette Use Among Youth and Young
Adults 2016 Report of the Surgeon General, the most commonly cited reasons for using e-cigarettes among both youth
and young adults are:
1. Curiosity.
2. Flavor/taste.
3. Low perceived harm.
4. Aid to quit conventional cigarettes.
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