Influence of ethnicity on the efficacy and utilization of bariatric surgery in the USA

Sociodemographic factors related to bariatric follow-up appointment attendance and weight outcomes

BACKGROUND

Follow-up care after bariatric surgery is essential in preventing postsurgical complications and promoting long-term weight loss maintenance. However, many patients do not attend postsurgical appointments with the bariatric team, which may contribute to poor surgical outcomes.

OBJECTIVES

This study sought to understand sociodemographic factors related to follow-up appointment attendance and weight outcomes. The first objective was to determine whether there was a relationship between 1-year follow-up appointment attendance and sociodemographic factors. The second objective was to determine whether patients from certain sociodemographic groups were more likely to attend a 2-year follow-up appointment. The third objective was to determine whether there were differences in weight outcomes for patients who attended follow-up appointments compared with those who did not attend.

SETTING

University hospital, United States.

METHODS

This study was a retrospective observational study. Participants included 841 adult patients who underwent bariatric surgery, of whom 505 (60.05%) attended a 1-year appointment with the bariatric team (348 attended a follow-up visit with another medical provider), and 398 (47.32%) who had any follow-up medical visit at 2 years after surgery. Sociodemographic variables were collected during a presurgical psychological evaluation. Weight-related variables were obtained through patients' electronic medical records 12 and 24 months after surgery.

RESULTS

Younger patients and those with lower education levels were less likely to attend the 1-year follow-up appointment with the bariatric team. People who attend 1-year follow-up with bariatric team have more favorable weight outcomes at 1 year and 2 years after surgery.

CONCLUSIONS

Follow-up appointment attendance with the bariatric team may be a critical factor in the effectiveness of bariatric surgery. Bariatric surgery teams should employ strategies to increase attendance at the 1-year follow-up visit with the surgical team. Additional strategies should be enacted to increase follow-up appointment attendance for patients with lower education levels.

COVID-19-Related Increases in Depressive and Anxious Symptoms Are Associated with Maladaptive Eating Among Patients up to 4 years Post-bariatric Surgery

INTRODUCTION

Depressive and anxious symptoms and maladaptive eating behaviors fluctuate with stressful events for patients seeking bariatric surgery. These associations are less clear for patients postoperatively. Using the COVID-19 pandemic as a frame, we examined associations between changes in depressive and anxious symptoms and maladaptive eating behaviors between up to four years postoperatively.

METHODS

Participants (N = 703) who underwent surgery between 2018 and 2021 completed web-based questionnaires between 2021 and 2022. Demographic and surgical data were obtained from electronic health records. Participants reported whether depressive and anxious symptoms increased or were stable/decreased during the COVID-19 pandemic, and completed eating behavior measures.

RESULTS

Many participants reported increased depressive (27.5%) and anxious (33.7%) symptoms during the COVID-19 pandemic. Compared to those who reported stable or decreased symptoms, these participants were as follows: (1) more likely to endorse presence of binge, loss-of-control, graze, and night eating; (2) reported higher emotional eating in response to anger and frustration, depression, and anxiety; and (3) reported higher driven and compulsive eating behaviors. Frequency of binge, loss-of-control, graze, and night eating episodes did not differ between groups (e.g., increased vs. stable/decreased anxious symptoms) among participants who endorsed any episodes.

CONCLUSION

A large portion of the sample reported increased depressive and anxious symptoms during the COVID-19 pandemic, and these increases were associated with maladaptive eating behaviors. Depressive and anxious symptoms and eating behaviors should be assessed postoperatively as significant stressors may be associated with increased distress and maladaptive eating behaviors that can affect postoperative outcomes. Postoperative interventions may be useful at simultaneously targeting these concerns.

Racial differences after bariatric surgery: 24-month follow-up of a randomized, controlled trial for postoperative loss-of-control eating

BACKGROUND

While some bariatric surgery outcomes vary by race/ethnicity, less is known about racial/ethnic differences in loss-of-control (LOC) eating and psychosocial outcomes post-surgery.

OBJECTIVE

This prospective study examined and extended initial short-term findings regarding racial differences in post-bariatric surgery LOC eating and weight loss to longer-term outcomes through 24-month follow-ups.

SETTING

Academic medical center in the United States.

METHODS

Participants were 140 patients (46.4% non-White) in a 3-month randomized, controlled trial for LOC eating performed about 6 months after bariatric surgery. Participants were reassessed at 6, 12, 18, and 24 months after treatment ended (about 33 mo after surgery). Doctoral assessors administered the Eating Disorder Examination-Bariatric Surgery Version interview to assess LOC eating and eating-disorder psychopathology at 12- and 24-month follow-ups. The Beck Depression Inventory II was repeated, and measured weight was obtained at all follow-ups.

RESULTS

White patients had significantly greater percent excess weight loss at all follow-ups than non-White patients (p < .03). White patients reported significantly more LOC eating at 12- (p = .004) and 24-month (p = .024) follow-ups and significantly greater eating disorder psychopathology at 12-month follow-up (p < .028). Racial groups did not differ significantly in eating disorder psychopathology at 24-month follow-ups or in Beck Depression Inventory II depression scores at any follow-ups.

CONCLUSIONS

Our findings suggest that among patients with LOC eating after bariatric surgery, non-White patients attain a lower percent excess weight loss than White patients but have comparable or better outcomes in LOC eating, associated eating disorder psychopathology, and depression over time.

Association Between Patient Satisfaction With Their Patient-Physician Relationship and Completion of Bariatric Surgery by Race and Ethnicity Among US Adults

IMPORTANCE

Metabolic and bariatric surgery (MBS) is an effective and safe treatment for obesity and its comorbidities, but less than 50% of those who are eligible and referred for MBS complete the procedure. The patient-physician relationship could be a decisive factor in the decision to complete MBS; however, this relationship has not been explored, particularly among racially and ethnically diverse populations.

OBJECTIVE

To examine the association between patient-reported satisfaction with their patient-physician relationship and MBS completion by self-reported racial and ethnic group.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 408 patients who were referred to a bariatric surgeon or obesity medicine program between July 24, 2019, and May 19, 2022.

EXPOSURE

Patient satisfaction with their physician was measured by 7 dimensions (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with physician, and accessibility and convenience) using the Patient Satisfaction Questionnaire Short Form.

MAIN OUTCOMES AND MEASURES

Completion status for MBS (yes or no).

RESULTS

A total of 408 patients (mean [SD] age, 47.3 [11.6] years; among 366 with data available, 317 [86.6%] women and 49 [13.4%] men) were included in the study. Of 363 patients with data available on race and ethnicity, 66 were Hispanic/Latinx (18.2%), 136 (37.5%) were non-Hispanic Black, 146 (40.2%) were non-Hispanic White, and 15 (4.1%) were other race or ethnicity. A total of 124 patients (30.4%) completed MBS. Overall, the mean (SD) patient satisfaction score was significantly greater in MBS completers vs noncompleters (3.86 [0.56] vs 3.61 [0.64]; P < .001). Multivariable logistic regression analysis showed technical quality was the most significant factor for MBS completion (adjusted odds ratio [aOR], 1.99 [95% CI, 1.24-3.19]), followed by communication (aOR, 1.78 [95% CI, 1.16-2.72]) and accessibility and convenience (aOR, 1.61 [95% CI, 1.03-2.53]). The interaction between racial and ethnic groups and patient satisfaction was not significant (eg, mean [SD] score for Hispanic/Latinx completers, 3.95 [0.55] vs 3.77 [0.60] for non-Hispanic White completers; P = .46 for interaction).

CONCLUSIONS AND RELEVANCE

These findings suggest that there is an association between patient satisfaction with the patient-physician relationship and the decision to complete MBS regardless of race and ethnicity. These findings have important implications for strategies to improve the proportion of qualified patients who complete MBS to achieve improved health outcomes.

The Role of Ethnic Disparities in the Outcomes of Bariatric Surgery: A Systematic Review and Meta-Analysis

Bariatric surgery is increasingly performed over the past decade for the treatment of morbid obesity. It has beneficial effects on weight reduction, along with diabetes remission. Conflicting results have been reported to evaluate the effect of ethics differences on the outcomes of bariatric surgery. We conducted this meta-analysis to outline the effects of ethnic differences on the outcomes of bariatric surgery, including weight reduction, biochemical variables, diabetes, and hypertension remission. A comprehensive literature search was conducted, using PubMed, Web of Science (ISI), Google Scholar, Popline, Global Health Library (GHL), Virtual Health Library (VHL) including Cochrane database, New York Academy of Medicine (NYAM), and System for Information on Grey Literature in Europe (SIGLE) for studies reporting body mass index (BMI), percentage of excess weight loss (%EWL), waist circumference, hypertension, lipid profile, and diabetes variables. We used the National Heart, Lung, and Blood Institute (NHLBI) tool (Bethesda, MD: NHLBI, National Institutes of Health {NIH}) for quality assessment. Comprehensive Meta-Analysis version 2 software (Englewood, NJ: Biostat, Inc.) was applied to perform the meta-analysis of the variables of interest. We included 23 studies of 71,679 subjects, who underwent bariatric surgery. The majority of the included cases were Whites 55,030 (77%), while 705 (1%) were Asians. The percentages of Blacks, African Americans, Hispanics, and Non-Hispanics were 9.3%, 1.3%, 10.4%, and 1%, respectively. BMI showed no significant difference between Whites vs African American and Hispanic vs Non-Hispanic groups (MD: 0.858; 95% CI: 3.408-1.691; p = 0.509 and MD: 0.455; 95% CI: 2.444-1.554; p = 0.663, respectively). The same result was reported for %EWL, comparing Whites vs African Americans. Lipid biochemical variables, diabetes remission, and hypertension control were significantly more seen among the Asian population. In conclusion, we reported a significant ethnic diversity and reduction in waist circumference, hyperlipidemia, and the associated morbidity one year after bariatric surgery in the Asian population. Further, high-quality prospective studies should focus on the social and psychological ethnic differences associated with obesity.

Are Geographical Health Accessibility and Socioeconomic Deprivation Associated with Outcomes Following Bariatric Surgery? A Retrospective Study in a High-Volume Referral Bariatric Surgical Center

PURPOSE

Few studies have evaluated the association between non-clinical determinants (socioeconomic status and geographic accessibility to healthcare) and the outcomes of bariatric surgery, with conflicting results. This study aimed to evaluate this association.

METHODS

The medical records of 1599 consecutive patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between June 2005 and December 2017 were retrieved. All relevant data, including patient characteristics, biometric values before and after surgery, related medical problems, surgical history, medications, and habitus, for each patient were prospectively collected in a database. Logistic regressions were used to assess the influence of non-clinical determinants on surgical indications and complications. Multilevel linear or logistic regression was used to evaluate the influence of non-clinical determinants on long-term %TWL and the probability to achieve adequate weight loss (defined as a %TWL > 20% at 12 months).

RESULTS

Analysis of the 1599 medical records revealed that most geographically isolated patients were more likely to have undergone laparoscopic Roux-en-Y gastric bypass (odds ratio: 0.97; 95% confidence interval: 0.94 to 0.99; P = 0.018) and had a greater likelihood of adequate weight loss (β: 0.03; 95% CI: 0.01 to 0.05; P = 0.021). Conversely, socioeconomic status (measured by the European Deprivation Index) did not affect outcomes following bariatric surgery.

CONCLUSION

Geographical health isolation is associated with a higher probability to achieve adequate weight loss after 1 year of follow-up, while neither health isolation nor socioeconomic deprivation is associated with post-operative mortality and morbidity. This results suggests that bariatric surgery is a safe and effective tool for weight loss despite socioeconomic deprivation.

Racial disparities in bariatric surgery postoperative weight loss and patient satisfaction

BACKGROUND

A growing body of evidence has demonstrated racial disparities in bariatric surgery (BS) outcomes. We aimed to investigate the impact of race on postoperative percent excess weight loss (%EWL) and patient satisfaction.

METHODS

Single center retrospective study of patients who underwent BS January 2012 to November 2017. Statistical analysis utilized Chi-squared, ANOVA and multivariable regression.

RESULTS

A total of 378 patients were included. African American patients lost significantly less weight compared to Caucasian and Hispanic patients (39.0 %EWL, 53.4 %EWL and 52.3 %EWL, respectively). A significant difference remained after adjustment for possible confounders. No difference in postoperative satisfaction was found.

CONCLUSIONS

Our study adds to the existing literature demonstrating racial disparities in BS postoperative EWL, despite adjusting for possible confounders, while contributing to the limited literature examining Hispanic patients. Furthermore, we examined an understudied outcome in postoperative patient satisfaction and found no racial disparity despite disparity in EWL.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

The Effect of Social Determinants and Socioeconomic Status on Laparoscopic Roux-En-Y Gastric Bypass for Weight Loss: An Analysis of the National Inpatient Sample

Objective  In the United States, Black and Hispanic patients have a higher prevalence of obesity than Whites (49.6 vs. 44.8 vs. 42.2%, respectively). Despite higher rates of obesity among minority populations, bariatric surgery is performed at higher obesity levels in minorities than in Whites. This study examines the effects of various socioeconomic factors such as race, payer type, and income on the likelihood of undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) at class II versus class III obesity and their associated complications. Materials and Methods  National Inpatient Sample (NIS) from 2016 to 2017 was queried to identify patients at least 18 years of age with a concomitant diagnosis of class II or class III obesity who underwent LRYGB. We analyzed obesity level at the time of LRYGB (class II vs. class III), postoperative intestinal obstruction during the admission, and occurrence of any noninfectious complication related to the surgery as our main outcomes. A multivariate logistic regression model was utilized to assess the association between our outcomes and socioeconomic factors associated with the admission. Results  A total of 76,405 LRYGB operations were included. Out of this total, 83% (63,640) LRYGB operations were in class III obesity. Black patients had a lower rate (11.6%) of LRYGB procedures at class II obesity than White (17.6%) and Hispanic (18%) patients ( p  < 0.001). Medicare, Medicaid, and lower income quartiles also showed lower rates of operation at class II obesity ( p  < 0.001). Black patients were 29% (95% confidence interval [CI]: 0.61-0.83, p  < 0.001) less likely than Whites to have a LRYGB procedure at class II obesity, they were 119% (95% CI: 1.17-4.11, p  = 0.0014) more likely to suffer a postoperative intestinal obstruction, and they were 93% (95% CI: 1.31-2.84, p  < 0.001) more likely to suffer a noninfectious complication. Conclusion  Socioeconomic disparities in the surgical management of severe obesity persist in the United States, especially for LRYGB. This study highlights multiple demographic factors that led to LRYGB at later obesity levels. Black patients were also more likely to be associated with postoperative complications during the admission. The determinants of health disparities in obese patients need to be examined further to reduce potential long-term morbidity and mortality in minorities. Further research is also required to identify the adverse effects of health disparities in patients with severe obesity and obesity-related comorbidities.

Racial disparities in bariatric surgery postoperative weight loss and co-morbidity resolution: a systematic review

While bariatric surgery is an accepted treatment for morbid obesity, the impact of race on surgical outcomes remains unclear. This systematic review aims to compare differences in weight loss and co-morbidity outcomes among various races after bariatric surgery. PubMed, Medline, and SCOPUS databases were queried to identify publications that included more than 1 racial group and reported weight loss outcomes after bariatric surgery. A total of 52 studies were included. Non-Hispanic black (NHB) patients comprised between 5.5% and 69.7% and Hispanic patients comprised between 4.7% and 65.3% of the studies' populations. Definitions of weight loss success differed widely across studies, with percent excess weight loss being the most commonly reported outcome, followed by percent total weight loss and change in body mass index (BMI). Statistical analyses also varied, with most studies adjusting for age, sex, preoperative weight, or BMI. Some studies also adjusted for preoperative co-morbidities, including diabetes mellitus, hypertension, and hyperlipidemia, or socioeconomic status, including income, education, and neighborhood poverty. The majority of studies found less favorable weight loss in NHB compared to Hispanic and non-Hispanic white (NHW), patients while generally no difference was found between Hispanic and NHW patients. The trend also indicates no association between race and resolution of obesity-related co-morbidities. Racial minorities lose less weight than NHW patients after bariatric surgery, although the factors associated with this discrepancy are unclear. The heterogeneity in reporting weight loss success and statistical analyses amongst the literature makes an estimation of effect size difficult. Generally, racial disparity was not seen when examining co-morbidity resolution after surgery. More prospective, robust, long-term studies are needed to understand the impacts of race on bariatric surgery outcomes and ensure successful outcomes for all patients, regardless of race.

Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry

Background

Racial disparities in postoperative complications have been demonstrated in bariatric surgery, yet the relationship of race to complication severity is unknown.

Study Design

Adult laparoscopic primary bariatric procedures were queried from the 2015 and 2016 MBSAQIP registry. Adjusted logistic and multinomial regressions were used to examine the relationships between race and 30-day complications categorized by the Clavien-Dindo grading system.

Results

A total of 212,970 patients were included in the regression analyses. For Black patients, readmissions were higher (OR = 1.39, p < 0.0001) and the odds of a Grade 1, 3, 4, or 5 complication were increased compared with White patients (OR = 1.21, p < 0.0001; OR = 1.21, p < 0.0001; OR = 1.22, p = 0.01; and OR = 1.43, p = 0.04) respectively. The odds of a Grade 3 complication for Hispanic patients were higher compared with White patients (OR = 1.59, p < 0.0001).

Conclusion

Black patients have higher odds of readmission and multiple grades of complications (including death) compared with White patients. Hispanic patients have higher odds of a Grade 3 complication compared with White patients. No significant differences were found with other races. Specific causes of these disparities are beyond the limitations of the dataset and stand as a topic for future inquiry.

Psychosocial Factors that Inform the Decision to Have Metabolic and Bariatric Surgery Utilization in Ethnically Diverse Patients

BACKGROUND

Metabolic and bariatric surgery (MBS) is currently the only clinically proven method of weight loss that is effective in treating severe obesity and its related comorbidities. However, only about 36% of MBS-eligible patients complete MBS. This qualitative study used the psychosocial framework to identify barriers and facilitators to MBS utilization among patients who had been referred to, or were considering MBS, but had not completed it.

METHODS

A combination of focus groups and in-depth interviews were utilized (Spring 2019) among ethnically diverse patients (N = 29, 82% female, 62% non-Hispanic Black, 10% Hispanic) who were considering MBS. All data was audio recorded, transcribed, and coded. Interview questions were grouped by the four psychosocial model domains (intrapersonal, interpersonal, organization/clinical interaction, societal/environmental) within the context of why patients would/would not follow through with MBS. The analysis included a combination of deductive and inductive approaches to generate the final codebook. Then, each code was input into Dedoose to identify overarching themes and sub-themes.

RESULTS

A total of 9 themes and 17 subthemes were found. Two major intrapersonal themes and four subthemes were identified as facilitators to MBS utilization and included a desire for improvement in existing comorbidities, mobility, and anticipated changes in physical appearance. Primary barriers to MBS completion included concerns about potential change in dietary behaviors post-MBS and safety of procedure.

CONCLUSIONS

Providing educational materials to address MBS common fears and misconceptions may increase utilization rates. Providing community-based pre- and post-support groups for this patient population may also increase MBS completion rates.

Exploring racial disparity in perioperative outcomes following revisional bariatric surgery: A case-control matched analysis

INTRODUCTION

Bariatric surgery is associated with 20-30% weight recidivism. As a result, revisional bariatric operation is increasingly performed. Disparity in bariatric outcomes remains controversial and very little is known about revisional bariatric surgery outcomes in ethnic cohorts.

METHODS

Revisional bariatric cases were identified from the 2015 and 2016 Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File. 1:1 case-control matching was performed and perioperative outcomes compared between racial cohorts.

RESULTS

24,197 cases were analyzed, including 20.78% Black patients. At baseline, there were differences in demographics and pre-existing conditions between racial cohorts. Matched analysis compared 7,286 Black and White patients. Operative duration (p = 0.008) and length of stay (p = 0.0003) were longer in Black patients. Readmission (6.8% vs. 5.4%, p = 0.009) was higher in Black patients. Bleeding (0.82% vs. 0.38%, p = 0.02) and surgical site infection (SSI) (2.6% vs. 1.8%, p = 0.01) were higher in White patients.

CONCLUSION

Revisional bariatric surgery is safe. Apart from a higher rate of bleeding, SSI and readmission, outcomes were not mediated by race.

Preoperative bariatric surgery programme barriers facing Pacific patients in Auckland, New Zealand as perceived by health sector professionals: a qualitative study

Minority ethnic patient groups typically have the highest bariatric surgery preoperative attrition rates and lowest surgery utilisation worldwide. Eligible patients of Pacific Island ethnicity (Pacific patients) in New Zealand (NZ) follow this wider trend.

OBJECTIVES

The present study explored structural barriers contributing to Pacific patients' disproportionately high preoperative attrition rates from publicly-funded bariatric surgery in Auckland, NZ.

SETTING

Publicly-funded bariatric surgery programmes based in the wider Auckland area, NZ.

DESIGN

Semi-structured interviews with health sector professionals (n=21) were conducted.Data were analysed using an inductive thematic approach.

RESULTS

Two primary themes were identified: (1) Confidence negotiating the medical system, which included Emotional safety in clinical settings and Relating to non-Pacific health professionals and (2) Appropriate support to achieve preoperative goals, which included Cultural considerations, Practical support and Relating health information. Clinical environments and an under-representation of Pacific staff were considered to be barriers to developing emotional safety, trust and acceptance of the surgery process with patients and their families. Additionally, economic deprivation and lower health literacy impacted preoperative goals.

CONCLUSIONS

Health professionals' accounts indicated that Pacific patients face substantial levels of disconnection in bariatric surgery programmes. Increasing representation of Pacific ethnicity by employing more Pacific health professionals in bariatric teams and finding novel solutions to implement preoperative programme components have the potential to reduce this disconnect. Addressing cultural competency of staff, increasing consultancy times and working in community settings may enable staff to better support Pacific patients and their families. Programme structures could be more accommodating to practical barriers of attending appointments, managing patients' preoperative health goals and improving patients' health literacy. Given that Pacific populations, and other patients from minority ethnic backgrounds living globally, also face high rates of obesity and barriers accessing bariatric surgery, our findings are likely to have broader applicability.

Association of Race With Bariatric Surgery Outcomes

Importance

The outcomes of bariatric surgery vary considerably across patients, but the association of race with these measures remains unclear.

Objective

To examine the association of race on perioperative and 1-year outcomes of bariatric surgery.

Design, Setting, and Participants

Propensity score matching was used to assemble cohorts of black and white patients from the Michigan Bariatric Surgery Collaborative who underwent a primary bariatric operation (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding) between June 2006 and January 2017. Cohorts were balanced on baseline characteristics and procedure. Conditional fixed-effects models were used to evaluate the association of race on outcomes within hospitals and surgeons. Data analysis occurred from June 2006 through August 2018.

Main Outcomes and Measures

Thirty-day complications and health care resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction.

Results

In each group, 7105 patients were included. Black patients had a higher rate of any complication (628 [8.8%] vs 481 [6.8%]; adjusted odds ratio, 1.33 [95% CI, 1.17-1.51]; P = .02), but there were no significant differences in the rates of serious complications (178 [2.5%] vs 135 [1.9%]; adjusted odds ratio, 1.32 [95% CI, 1.05-1.66]; P = .29) or mortality (5 [0.10%] vs 7 [0.10%]; adjusted odds ratio, 0.73 [95% CI, 0.23-2.31]; P = .54). Black patients had a greater length of stay (mean [SD], 2.2 [3.0] days vs 1.9 [1.7] days; adjusted odds ratio, 0.30 [95% CI, 0.20-0.40]; P < .001), as well as a higher rate of emergency department visits (541 [11.6%] vs 826 [7.6%]; adjusted odds ratio, 1.60 [95% CI, 1.43-1.79]; P < .001) and readmissions (414 [5.8%] vs 245 [3.5%]; adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P < .001). At 1 year, black patients had lower mean total body weight loss and as a percentage of weight (32.0 kg [26%]; vs 38.3 kg [29%]; P < .001) and this held true across procedures. Remission of hypertension was lower for black patients (564 [40.0%] vs 1096 [56.0%]; P < .001), but the rate of sleep apnea remission (467 [62.6%] vs 615 [56.1%]; P = .005) and gastroesophageal reflux disease (309 [78.6%] vs 453 [75.4%]; P = .049) were higher. There were no significant differences in remission of diabetes with insulin dependence, diabetes without insulin dependence,or hyperlipidemia hyperlipidemia. Fewer black patients than white patients reported a good or very good quality of life (1379 [87.2%] vs 2133 [90.4%]; P = .002) and being very satisfied with surgery (1908 [78.4%] vs 2895 [84.2%]; P < .001) at 1 year.

Conclusions and Relevance

Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients. While sleep apnea and gastroesophageal reflux disease remission were higher and hypertension remission lower in black patients, comorbidity remission was otherwise similar between matched cohorts. Racial and cultural differences among patients should be considered when designing strategies to optimize outcomes with bariatric surgery.

The Impact of Ethnicity on Metabolic Outcomes After Bariatric Surgery

BACKGROUND

Previous studies have demonstrated that ethnic minority patients experience significant metabolic improvements after bariatric surgery but less so than non-Hispanic whites. Previous research has primarily investigated differences between non-Hispanic white and black patients. Thus, there remains a need to assess differences in diabetic outcomes among other ethnic groups, including Hispanic and Asian patient populations.

MATERIALS AND METHODS

A retrospective analysis including 650 patients with type II diabetes mellitus (T2DM), who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy (LSG) procedures, was conducted to understand ethnic disparities in diabetic metabolic outcomes, including weight loss, serum concentrations of glucose, fasting insulin, and hemoglobin A1c (HbA1c). Data were from a single academic institution in northern California. Ethnicity data were self reported. T2DM was defined as having one or more of the following criteria: a fasting glucose concentration >125 mg/dL, HbA1c >6.5%, or taking one or more diabetic oral medications. Diabetes resolution was defined as having a fasting glucose <125 mg/dL, a HbA1c <6.5%, and discontinuation of diabetic oral medications.

RESULTS

Within-group comparisons in all ethnic groups showed significant reductions in body mass index, body weight, fasting insulin, fasting glucose, and HbA1c by 6 mo, but Asian patients did not experience further improvement in body mass index or diabetic outcomes at the 12-mo visit. Black patients did not experience additional reductions in fasting insulin or glucose between the 6- and 12-mo visit and their HbA1c significantly increased. Nevertheless, the majority of patients had diabetes remission by the 12-mo postoperative visit (98%, 97%, 98%, and 92% in Non-Hispanic, Hispanic, black, and Asian, respectively).

CONCLUSIONS

The results of this study demonstrate that bariatric surgery serves as an effective treatment for normalizing glucose metabolism among patients with T2DM. However, this study suggests that additional interventions that support black and Asian patients with achieving similar metabolic outcomes as non-Hispanic white and Hispanic patients warrant further consideration.

Surgical Treatment of Obesity in Latinos and African Americans: Future Directions and Recommendations to Reduce Disparities in Bariatric Surgery

Introduction: Obesity and metabolic syndrome are increasingly prevalent in the United States, particularly among African Americans and Latinos. Bariatric surgery has become one of the primary treatment modalities for obesity and type 2 diabetes. However, fewer Latinos and African Americans are undergoing bariatric surgery than whites. The aim of this article is to describe the disparities in seeking and accessing bariatric surgery, describe the outcomes following bariatric procedures in Latinos and African Americans, and offer recommendations and future research directions that may assist in addressing these disparities. Methods: Original research and review articles published in English were reviewed. Results: Potential reasons why Latinos and African Americans have low rates of seeking bariatric surgery are described. Disparities in access to care and financial coverage, low rates of referral by primary care providers, and cultural attitudes toward obesity in conjunction with mistrust of the healthcare system are discussed as potential contributors to the low rate of bariatric surgery in Latinos and African Americans. Finally, disparities in bariatric surgery outcomes, comorbidities, and complications are reviewed. Conclusions: Additional research studies in bariatric surgical disparities are needed. Recommendations and future directions that may help to reduce disparities in bariatric surgery are discussed.

Patient perspectives about bariatric surgery unveil experiences, education, satisfaction, and recommendations for improvement

BACKGROUND

Following bariatric surgery, up to 35% of patients struggle with strict regimens and experience weight recidivism within 2 years [1-5]. Accredited weight management centers (WMC) must provide educational programs and support patients in lifestyle changes before and after surgery. Educational programs, however, may not be evidence-based or patient-centered and may vary in curriculum, approach, and educator type [6].

OBJECTIVE

To obtain patient descriptions about the weight loss surgery (WLS) experience, including education, satisfaction, and recommendations for improvement.

SETTING

Participants were recruited from a university hospital-based WMC in Pennsylvania.

METHODS

This qualitative descriptive study used purposive sampling and inductive content analysis.

RESULTS

A NEW ME-VERSION 2.0, encompassed themes from semistructured interviews with 11 participants (36% male). Theme 1: Programming and Tools, explained how individuals undergoing WLS found support through educational programming. Theme 2: Updates and Upgrades, identified issues surrounding quality of life and challenges before and after surgery. Theme 3: Lessons Learned and Future Considerations, identified satisfaction levels and recommendations for improving the WLS experience. Participants reported positive experiences, acknowledging educational programs and extensive WMC resources, yet also offered recommendations for improving educational programming.

CONCLUSION

Patient narratives provided evidence about the WLS experience. Achievement of weight goals, adherence to rules, and improved health status contributed to perceptions of WLS success. Participants encouraged educators to identify expected outcomes of educational programming, monitor holistic transformations, foster peer support, and use technology in WMC programming. Results also validated the need for the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program's education requirement (standard 5.1). Future educational research could help develop best practices in WLS patient education and assess associations between education and clinical outcomes.

Type 2 diabetes mellitus outcomes after laparoscopic gastric bypass in patients with BMI <35 kg/m2 using strict remission criteria: early outcomes of a prospective study among Mexicans

BACKGROUND

Mild obesity (BMI 30-34.9 kg/m²) is highly prevalent worldwide and is associated with type 2 diabetes mellitus. The efficacy of bariatric surgery remains unclear, including among Mexicans. The criteria for diabetes remission are inconsistent, as they are based on different thresholds for glycated hemoglobin, with remission rates ranging from 43 to 73%.

METHODS

Mildly obese patients with type 2 diabetes mellitus who underwent laparoscopic gastric bypass were prospectively analyzed. The primary objective was to determine the impact of surgery on their metabolic profiles. Demographic, clinical, and biochemical parameters were measured at baseline and at 3, 6, 9, 12, and 18 months. Diabetes remission rate was defined as an HbA1c <5.7%. Complications within 30 days and weight loss (% total weight loss) were also analyzed.

RESULTS

Twenty-three Mexican patients underwent surgery. Of the 19 patients, evaluable at 18 months, nine (47.4%) achieved complete diabetes remission, seven (36.8%) showed partial remission, and three (15.8%) showed improvement. Significant improvements in lipid profile, cardiovascular risk, blood pressure, and every metabolic parameter were observed, beginning at the first month and throughout the study. The final total percentage weight loss was 24.9%. Three patients (13%) experienced complications, but none required reoperation or died.

CONCLUSION

Laparoscopic gastric bypass is a safe and effective method to improve the metabolic profile of mildly obese Mexican patients with type 2 diabetes mellitus, inducing high remission rates even when the strictest model is used.

The medicalization of obesity, bariatric surgery, and population health

This article examines how the medicalization of obesity validates the use of bariatric surgery to treat obesity in the United States and how expansions in access to bariatric surgery normalize surgical procedures as disease treatment and prevention tools. Building on this discussion, the article poses two questions for population health regarding health technology: (1) to what extent does bariatric surgery treat obesity in the United States while diverting attention away from the ultimate drivers of the epidemic and (2) to what extent does bariatric surgery improve outcomes for some groups in the US population while simultaneously generating disparities? We conduct a brief, historical analysis of the American Medical Association’s decision to reclassify obesity as a disease through internal documents, peer-reviewed expert reports, and major media coverage. We use medicalization theory to show how this decision by the American Medical Association channels increased focus on obesity into the realm of medical intervention, particularly bariatric surgery, and use this evidence to review research trends on bariatric surgery. We propose research questions that investigate the population health dimensions of bariatric surgery in the United States and note key areas of future research. Our objective is to generate a discourse that considers bariatric surgery beyond the medical realm to better understand how technological interventions might work collectively with population-level obesity prevention efforts and how, in turn, population health approaches may improve bariatric surgery outcomes.

Ethnic Considerations for Metabolic Surgery

Obesity and diabetes represent twin health concerns in the developed world. Metabolic surgery has emerged as an established and enduring treatment for both obesity and diabetes. As the burden of obesity and diabetes varies upon the basis of ethnicity, it is also apparent that there may be differences for indications and outcomes for different ethnic groups after metabolic surgery. Whereas there appears to be evidence for variation in weight loss and complications for different ethnic groups, comorbidity remission particularly for diabetes appears to be free of ethnic disparity after metabolic surgery. The impacts of access, biology, culture, genetics, procedure, and socioeconomic status upon metabolic surgery outcomes are examined. Further refinement of the influence of ethnicity upon metabolic surgery outcomes is likely imminent.

Bariatric surgery outcomes in ethnic minorities

BACKGROUND

The primary aim of this study was to examine percent excess weight loss (%EWL) across and between racial groups at 6, 12, 24, and 36 months follow-up in patients who received sleeve gastrectomy (SG) or a Roux-en-Y gastric bypass (RYGB) operation. We hypothesized that ethnic minorities (blacks and Hispanics) would have a lower %EWL than whites at 6, 12, 24, and 36 months for both SG and RYGB operations. The secondary aim was to examine %EWL within racial groups at 6, 12, 24, and 36 months as a function of the type of bariatric operation. We hypothesized that whites, blacks, and Hispanics would have a greater %EWL with RYGB than with SG.

METHODS

A total of 749 patients who underwent an SG or an RYGB operation from January 2008 to June 2014 were included. Data were collected from patients' electronic medical records. Self-reported data on race/ethnicity were also obtained from the electronic medical record and were classified into the following categories: white, Hispanic/Latino, African American or black, or other.

RESULTS

Results revealed overall differences in %EWL between blacks and whites (P < .05) and no overall differences in %EWL between Hispanics and whites (P = .697). Follow-up analyses revealed that Hispanics differed from blacks in %EWL at 6, 12, 24, and 36 months (all P < .01) and that whites differed from blacks at 6 months (P < .05). There were no significant differences between whites and Hispanics during any follow-up period. Overall, the %EWL differed by operation type (P < .01), with RYGB associated with greater %EWL than SG. When stratified by race, the only difference was found in blacks, who had a greater %EWL after RYGB compared with SG (P < .01).

CONCLUSION

Our primary hypothesis was partially supported, as blacks but not Hispanics had a lower %EWL compared to whites at 6 months. An interesting finding is that blacks had a lower %EWL than Hispanics at every time point. Moreover, our secondary hypothesis was partially supported. Results revealed that overall RYGB was related to greater %EWL compared with SG, and within racial groups, among blacks only, RYGB was associated with a greater %EWL compared with SG.

Effect of ethnicity on weight loss after bariatric surgery

BACKGROUND

Previous studies have reported better weight loss after bariatric surgery among non-Hispanic whites (NHW) versus non-Hispanic blacks (NHB) and Hispanics. The majority of these studies took place in areas where NHW are the majority. This study aimed to compare post-surgery weight outcomes by ethnicity in a geographic area where Hispanics are the majority.

METHODS

A retrospective medical chart review of 3268 patients (1561 Hispanic, 660 NHB, and 1047 NHW) who underwent Roux-en-Y gastric bypass (RYGB) or Adjustable Gastric Band (AGB) placement from 2002 to 2012 were analyzed. Percentages of excess weight loss (EWL) and body mass index (BMI) changes at 6, 12, and 24 months post-surgery were compared by ethnic group.

RESULTS

At 6 months, EWL was significantly different by ethnicity (52.7 ± 15.9 Hispanics, 49.7 ± 15.7 NHW, 43.0 ± 17.3 NHB, P < 0.001). These differences remained at 1 year (66.0 ± 20.3 Hispanics, 64.0 ± 20.3 NHW, 54.1 ± 21.3 NHB, P < 0.001) and 2 years (68.6 ± 24.1 Hispanics, 69.5 ± 21.2 NHW, 57.6 ± 25.4 NHB, P < 0.001). Ethnic group changes in BMI were similar to EWL changes. Analysis stratified by gender, type of surgery, and BMI category (<40, 40-49.99, ≥50 kg/m(2)) showed lower EWL in NHB than Hispanics and NHW. NHW had higher EWL than Hispanics only when they underwent AGB and had a BMI >40 kg/m(2).

CONCLUSIONS

Up to 2 years after RYGB, mean EWL and BMI reduction patterns are similar among NHW and Hispanics and significantly better than NHB. These patterns were comparable but not as pronounced among patients with AGB surgery. Our findings suggest that social factors may contribute to successful weight loss after bariatric surgery.

Association of race and socioeconomic status with outcomes following laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Obesity poses serious health consequences, and bariatric surgery remains the most effective and durable treatment. The goal of this study was to identify the association of race and socioeconomic characteristics with clinical outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

A retrospective review of all patients who underwent LRYGB between 2004 and 2010 was conducted. Outcomes analyzed included percent excess weight loss (%EWL), percent weight loss (%WL), change in body mass index (ΔBMI), and improvement or remission of obesity-associated medical conditions.

RESULTS

In total, 663 patients met inclusion criteria with 170 (25.6%) African Americans and 493 (74.4%) European Americans. When compared to European Americans, the African American group included significantly more women and had a significantly higher preoperative BMI and lower socioeconomic status. In adjusted analyses, African Americans had significantly lower %EWL, %WL, and ΔBMI than the European Americans at 1-, 2-, and 5-year intervals of follow-up. Adjusted spline models including all follow-up visits for all patients also demonstrated a significant difference between the races in %EWL, %WL, and ΔBMI. Both races had similar improvement or remission of type 2 diabetes mellitus, obstructive sleep apnea, hyperlipidemia, and hypertension.

CONCLUSION

Although African Americans had a statistically significant lower %EWL, %WL, and ΔBMI, both groups had durable weight loss and comparable rates of improvement or remission of obesity-associated comorbidities. Thus, both groups have significant improvement in their overall health after LRYGB.

Alcohol and Drug Use Among Postoperative Bariatric Patients: A Systematic Review of the Emerging Research and Its Implications

BACKGROUND

Emerging research suggests that some bariatric surgery patients are at a heightened risk for developing substance use problems, especially alcohol use problems.

METHODS

An exhaustive literature review was conducted in January 2015 to investigate all articles published that included data on postoperative alcohol use, alcohol use disorders, and illicit drug use among bariatric surgery patients.

RESULTS

Twenty-three studies reported on alcohol and/or substance use among bariatric patients. Six studies longitudinally assessed alcohol use behaviors; 3 of these studies found an increase in alcohol use following surgery. Six studies were cross-sectional, and 2 studies assessed medical records. Five studies investigated the prevalence of admissions to substance abuse treatment, and 3 studies combined alcohol and drug use data in a single index. Six studies reported on illicit drug use and reported low-postoperative use. The studies' samples were primarily non-Hispanic white females in their upper 40s, and only 11 of the 23 studies utilized validated assessment instruments.

CONCLUSIONS

Studies employing longitudinal designs and large sample sizes indicate that bariatric patients who had the gastric bypass procedure are at an elevated risk for alcohol use problems postoperatively. Research also indicates that bariatric surgery patients might be overrepresented in substance abuse treatment facilities. Risk factors for problematic postoperative alcohol use include regular or problematic alcohol use presurgery, male gender, younger age, tobacco use, and symptoms of attention deficient and hyperactivity disorder. As a whole, however, studies indicate bariatric surgery patients demonstrate a low prevalence of problematic alcohol use, and studies about gastric bypass patients are not entirely conclusive. Prospective, longitudinal studies are needed, utilizing standardized and validated alcohol assessment instruments that follow postoperative bariatric patients well beyond 2 years, and account for types of bariatric procedure. Finally, study samples with greater racial/ethnic diversity and wider age ranges are needed.

Factors Associated With Long-Term Weight Loss Following Bariatric Surgery Using 2 Methods for Repeated Measures Analysis

We used electronic health record data from 162 patients enrolled in the NUgene Project (2002-2013) to determine demographic factors associated with long-term (from 1 to up to 9.5 (mean = 5.6) years) weight loss following Roux-en-Y gastric bypass surgery. Ninety-nine (61.1%) patients self-reported white, and 63 (38.9%) self-reported black, mixed, or missing race. The average percent weight loss was -33.4% (standard deviation, 9.3) at 1 year after surgery and -30.7% (standard deviation, 12.5) at the last follow-up point. We used linear mixed and semiparametric trajectory models to test the association of surgical and demographic factors (height, surgery age, surgery weight, surgery body mass index, marital status, sex, educational level, site, International Classification of Diseases code, Current Procedural Terminology code, Hispanic ethnicity, and self-reported race) with long-term percent weight loss and pattern of weight loss. We found that black, mixed, and missing races (combined) in comparison with white race were associated with a decreased percent weight loss of -4.31% (95% confidence interval: -7.30, -1.32) and were less likely to have higher and sustained percent weight loss (P = 0.04). We also found that less obese patients were less likely to have higher and sustained percent weight loss (P = 0.01). These findings may be helpful to patients in setting expectations after weight loss surgery.

Clinical registries and quality measurement in surgery: a systematic review

BACKGROUND

Surgical clinical registries provide clinical information with the intent of measuring and improving quality. This study aimed to describe how surgical clinical registries have been used to measure surgical quality, the reported findings, and the limitations of registry measurements.

METHODS

Medline, CINAHL, and Cochrane were queried for English articles with the terms: "registry AND surgery AND quality." Eligibility criteria were studies explicitly assessing quality measurement with registries as the primary data source. Studies were abstracted to identify registries, define registry structure, uses for quality measurement, and limitations of the measurements used.

RESULTS

A total of 111 studies of 18 registries were identified for data abstraction. Two registries were financed privately, and 5 registries were financed by a governmental organization. Across registries, the most common uses of process measures were for monitoring providers and as platforms for quality improvement initiatives. The most common uses of outcome measures were to improve quality modeling and to identify preoperative risk factors for poor outcomes. Eight studies noted improvements in risk-adjusted mortality with registry participation; one found no change. A major limitation is bias from context and means of data collection threatening internal validity of registry quality measurement. Conversely, the other major limitation is the cost of participation, which threatens the external validity of registry quality measurement.

CONCLUSION

Clinical registries have advanced surgical quality definition, measurement, and modeling as well as having served as platforms for local initiatives for quality improvement. The implication of this finding is that subsidizing registry participation may improve data validity as well as engage providers in quality improvement.

Country of origin and bariatric surgery in Sweden during 2001-2010

BACKGROUND

The prevalence of obesity, as well as use of bariatric surgery, has increased worldwide. The aim of the present study was to investigate the potential differences in the use of bariatric surgery among Swedes and immigrants in Sweden and whether the hypothesized differences remain after adjustment for socioeconomic factors.

METHODS

A closed cohort of all individuals aged 20-64 years was followed during 2001-2010. Further analyses were performed in 2 periods separately (2001-2005 and 2006-2010). Age-standardized cumulative incidence rates (CR) of bariatric surgery were compared between Swedes and immigrants considering individual variables. Cox proportional hazards models were used in univariate and multivariate models for males and females.

RESULTS

A total of 12,791 Swedes and 2060 immigrants underwent bariatric surgery. The lowest rates of bariatric surgery were found in immigrant men. The largest difference in CR between Swedes and immigrants was observed among low-income individuals (3.4 and 2.3 per 1000 individuals, respectively). Adjusted hazard ratios (HRs) were lower for all immigrants compared with Swedes in the second period. The highest HRs were observed among immigrants from Chile and Lebanon and the lowest among immigrants from Bosnia. Except for Nordic countries, immigrants from all other European countries had a lower HR compared with Swedes.

CONCLUSIONS

Men in general and some immigrant groups had a lower HR of bariatric surgery. Moreover, the difference between Swedes and immigrants was more pronounced in individuals with low socioeconomic status (income). It is unclear if underlying barriers to receive bariatric surgery are due to patients' preferences/lack of knowledge or healthcare structures. Future studies are needed to examine potential causes behind these differences.

Morbidity, mortality, and weight loss outcomes after reoperative bariatric surgery in the USA

BACKGROUND

Obesity is successfully treated by bariatric operations, but some patients need reoperations. No large national studies are available to evaluate the safety and efficacy after reoperative bariatric surgery.

METHODS

Data from June 2007 through March 2012 from the Bariatric Outcomes Longitudinal Database were queried for safety and efficacy of reoperations and compared to those who had initial bariatric operations but did not undergo reoperations. Reoperations were subdivided into corrective operations and conversions.

RESULTS

Out of 449,753 bariatric operations, 28,720 (6.3%) underwent reoperations of which 19,970 (69.5%) were corrective and 8,750 (30.5%) were conversions. The conversion group compared to primary operations was older (47.63 ± 10.8 vs. 45.5 ± 11.8 years), had less males (13.5 vs. 21.3%), and had more African Americans (14.6 vs. 12%). Comparing primary operations to corrective and conversions operations, respectively, the following were observed: length of stay (1.78 ± 4.95 vs. 2.04 ± 6.44 and 2.86 ± 4.58 days), severe adverse events at 30 days (1.6 vs. 1.7 and 3.3%), severe adverse events at 1 year (2.15 vs. 1.9 and 3.61%), percent excess weight loss at 1 year (43.2 vs. 35.9 ± 92.4 and 39.3 ± 39.9%), 30-day mortality rate (0.1 vs. 0.12 and 0.21%), and 1-year mortality rate (0.17 vs. 0.24 and 0.31%). Comorbidities were resolved after both primary operations and reoperations.

CONCLUSIONS

Most bariatric surgery patients do not need reoperations. Among those who do, the complication rate is low and outcomes are clinically comparable to primary procedures.

Prevalence and characteristics of individuals without diabetes and hypertension who underwent bariatric surgery: lessons learned about metabolically healthy obese

BACKGROUND

Recent studies describe a unique subset of obese individuals with normal metabolic profiles despite having excess weight called "metabolically healthy but obese (MHO)". Our aim was to determine the prevalence of individuals without diabetes and hypertension and risk factors associated with the MHO phenotype among bariatric surgery patients.

METHODS

We conducted a retrospective study of 710 adults who underwent bariatric surgery at Johns Hopkins between 2008 and 2010. In the first analysis of 523 individuals, we identified 150 individuals without diabetes and hypertension; in the second analysis of 260 individuals, we identified 44 individuals without diabetes, hypertension and hypertriglyceridemia. We used multivariable logistic regression to examine the association between each group and potential risk factors including age, sex, race, body mass index, and presence of liver disease on liver biopsy.

RESULTS

The prevalence of individuals without diabetes and hypertension was 28.7%; among these individuals 88.7% had liver steatosis, 7.3% nonalcoholic steatohepatitis (NASH), and 19.3% liver fibrosis. These individuals were significantly more likely to be white OR=1.9 (95% CI: 1.1-3.1), younger OR=4.1 (95% CI=2.6-6.3), and female OR=2.1, (95% CI=1.2-3.6) and less likely to have liver steatosis OR=0.4 (95% CI=0.2-0.9) or NASH OR=0.3 (95% CI=0.2-0.6).

CONCLUSION

Among bariatric surgery patients, almost a third of patients do not have diabetes and hypertension and could be probably considered "MHO" and were more likely to be white, young, female, and have less liver injury. The high prevalence of liver steatosis in MHO individuals among bariatric surgery patients challenges the notion of MHO as a truly metabolically healthy entity.