Racial Disparity in Short-Term Outcomes after Gastric Bypass Surgery

Evaluating the Bariatric Safety Net: Analysis of Socioeconomic Factors and Outcomes at a Bariatric Safety Net Program Compared to an Affiliated Private Center

PURPOSE

Obesity is prevalent among economically disadvantaged and racially underrepresented populations. It has been suggested that socioeconomic factors, race, and lifestyle habits are important factors associated with weight loss and comorbidity remission after bariatric surgery. This study analyzes outcomes of bariatric surgery at a private hospital (PH) versus an affiliated safety-net hospital (SNH).

METHODS

Retrospective review of laparoscopic sleeve gastrectomies (LSG) performed by the same surgeons at a PH and SNH in a large metropolitan setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. A postoperative telephone survey was conducted to study dietary and lifestyle differences between cohorts.

RESULTS

Of the 243 LSG performed, 141 (58%) occurred at PH versus 102 (42%) at SNH. Most patients at SNH were Hispanic, lower socioeconomic status, and had government-sponsored insurance. Based off the results from the postoperative telephone survey, there were no significant differences in dietary and lifestyle habits between both cohorts. Postoperative weight loss outcomes were similar across cohorts. The two groups had similar percent excess weight loss (EWL) at all time points up to 36 months and similar rates of failure to achieve 50% EWL at 12 months. However, patients at PH had greater resolution of diabetes and hypertension after surgery.

CONCLUSION

Our study demonstrates outcomes after bariatric surgery are similar at a PH and its affiliated SNH. Despite differences in race and socioeconomic factors between the two cohorts, perioperative outcomes, short-term postoperative weight loss, and weight loss failure rates were equivalent between SNH and PH patients.

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.

Introducing a Bariatric Surgery Program at a Large Urban Safety Net Medical Center Serving a Primarily Hispanic Patient Population

Background

Few bariatric surgery programs exist at safety net hospitals which often serve patients of diverse racial and socioeconomic backgrounds. A bariatric surgery program was developed at a large urban safety net medical center serving a primarily Hispanic population. The purpose of this study was to evaluate safety, feasibility, and first-year outcomes to pave the way for other safety net bariatric programs.

Methods

The bariatric surgery program was started at a safety net hospital located in a neighborhood with over twice the national poverty rate. A retrospective review was performed for patient demographics, comorbidities, preoperative diet and exercise habits, perioperative outcomes, and 1-year outcomes including percent total weight lost (%TWL) and comorbidity reduction.

Results

A total of 153 patients underwent laparoscopic sleeve gastrectomy from May 2017 through December 2019. The average preoperative BMI was 47.9kg/m², and 54% of patients had diabetes. The 1-year follow-up rate was 94%. There were no mortalities and low complication rates. The average 1-year %TWL was 22.8%. Hypertension and diabetes medications decreased in 52% and 55% of patients, respectively. The proportion of diabetic patients with postoperative HbA1c <6.0% was 49%.

Conclusion

This is one of the first reports on the outcomes of a bariatric surgery program at a safety net hospital. This analysis demonstrates feasibility and safety, with no mortalities, low complication rates, and acceptable %TWL and comorbidity improvement. More work is needed to investigate the impacts of race, culture, and socioeconomic factors on bariatric outcomes in this population.

Graphical abstract

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.

Midterm Outcome of Laparoscopic Sleeve Gastrectomy in Asians: a Systematic Review and Meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Studies have suggested that LSG can provide effective and sustainable weight loss although most of them were conducted in Western populations. Our aim was to characterize the midterm outcome of LSG in Asians with obesity.

METHODS

MEDLINE and EMBASE were searched through August 2019 for studies that reported % total body weight loss (TBWL) and/or % excess weight loss (EWL) at 3 and/or 5 years among adult Asians with obesity who underwent LSG. Data on complications and surgical revision rate were also extracted. The pooled effect size and 95% confidence interval (CI) were calculated using a random effects model.

RESULTS

A total of 19 studies involving 6235 patients were included. The pooled mean %EWLs were 72.6% (95% CI 67.2-78.0, I² = 97%); 67.1% (95% CI 61.7-72.6, I² = 95%); and 59.1% (95% CI 48.8-69.4, I² = 94%) at 1, 3, and 5 years, respectively. The pooled mean %TBWLs were 32.1%, 29.0%, and 25.5% at 1, 3, and 5 years, respectively. The pooled rates of revision due to gastroesophageal reflux disease and weight regain were 1.9% and 2.5%, respectively.

CONCLUSIONS

Our meta-analysis suggests that LSG is an effective procedure for weight reduction that offers durable response for up to 5 years among Asians with obesity. The longer-term data is needed.

Factors Associated with Weight Loss After Metabolic Surgery in a Multiethnic Sample of 1012 Patients

BACKGROUND

Metabolic surgery is the most effective method for weight loss in the long-term treatment of morbid obesity and its comorbidities. The primary aim of this study was to examine factors associated with percent total weight loss (%TWL) after metabolic surgery among an ethnically diverse sample of patients.

METHODS

A retrospective review was performed on 1012 patients who underwent either a sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at our institution between January 2008 and June 2015.

RESULTS

African Americans had a lower %TWL than non-Hispanic/Latino Whites at 6, 9, 12, 18, and 48 months. At all timeframes, there was a negative association between pre-surgery TWL and %TWL after surgery. Female sex was negatively associated with %TWL at 3 months only. Higher initial BMI was also associated with greater post-operative %TWL at 18, 24 and 36 months. Older patients had lower %TWL at 6, 9, 12 and 24 months post-surgery. Patients who received RYGB had greater %TWL than those who received SG at 3, 6, 9, 12, 24 and 36 months.

CONCLUSIONS

African Americans had a lower %TWL than non-Hispanic/Latino Whites at most time points; there were no other significant race/ethnicity or sex differences. BMI (greater initial BMI), age (lower) and RYGB were associated with a greater post-operative %TWL at certain post-surgery follow-up time points. A limitation of this study is that there was missing data at a number of time points due to lack of attendance at certain follow-up visits.

Influence of Asian Ethnicities on Short- and Mid-term Outcomes Following Laparoscopic Sleeve Gastrectomy

PURPOSE

Prevalence of obesity in Asia has been on the increasing trend, with corresponding increase in utilisation of bariatric surgery. The objective of this study was to examine differences in weight loss outcomes following bariatric surgery between Asian ethnicities.

MATERIALS AND METHODS

A retrospective database review was conducted of patients undergoing primary laparoscopic sleeve gastrectomy between 2009 and 2013 in 14 centres from Singapore, Malaysia, Taiwan, Hong Kong, Japan, Korea, India, Australia, Switzerland, and the USA. All patients with available follow-up data at 12 months and 36 months post-surgery were included in this study. Outcome measures used were percentage excess weight loss (%EWL) and percentage total weight loss (%TWL). Differences in outcomes between ethnicities were analysed after adjusting for age, gender, baseline body mass index (BMI), and presence of diabetes.

RESULTS

The study population (n = 2150) consisted of 1122 Chinese, 187 Malays, 309 Indians, 67 Japanese, 259 Koreans, and 206 Caucasians. 67.1% were female and 32.9% were male. Mean age was 37.1 ± 11.2 years. Mean pre-operative BMI was 40.7 ± 8.1 kg/m². With the Caucasian population as reference, Japanese had the best %TWL (3.90, 95% CI 1.16-6.63, p < 0.05) and %EWL (18.55, 95% CI 10.33-26.77, p < 0.05) while the Malays had the worst outcomes. Both Chinese and Koreans had better %EWL but worse %TWL as compared to Caucasians and there were no significant differences with the Indian study group.

CONCLUSION

There are differences in weight loss outcomes following bariatric surgery between Asian ethnicities.

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.

Systemic F2-Isoprostane Levels in Predisposition to Obesity and Type 2 Diabetes: Emphasis on Racial Differences

This review focuses on racial differences in systemic levels of lipid peroxidation markers F₂-isoprostanes as metabolic characteristics predisposing to obesity and type 2 diabetes. Elevated levels F₂-isoprostanes were found in obesity, type 2 diabetes and their comorbidities. It was hypothesized that increased F₂-isoprostane levels reflect the obesity-induced oxidative stress that promotes the development of type 2 diabetes. However, African Americans have lower levels of systemic F₂-isoprostane levels despite their predisposition to obesity and type 2 diabetes. The review summarizes new findings from epidemiological studies and a novel interpretation of metabolic determinants of systemic F₂-isoprostane levels as a favorable phenotype. Multiple observations indicate that systemic F₂-isoprostane levels reflect intensity of oxidative metabolism, a major endogenous source of reactive oxygen species, and specifically, the intensity of fat utilization. Evidence from multiple human studies proposes that targeting fat metabolism can be a productive race-specific strategy to address the existing racial health disparities. Urinary F₂-isoprostanes may provide the basis for targeted interventions to prevent obesity and type 2 diabetes among populations of African descent.

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.

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.

Nonalcoholic Fatty Liver Disease in Latinos

Nonalcoholic fatty liver disease (NAFLD) is a serious public health concern that affects almost one third of the US population. The prevalence of NAFLD varies among ethnic/racial groups, with the Latin American population being affected disproportionately. The severity of NAFLD also may be greater in the Latino population. The increased prevalence and severity of NAFLD in Latino Americans likely is related to the interplay between issues such as genetic factors, access to health care, or the prevalence of chronic diseases such as metabolic syndrome or diabetes. In this review, we summarize the current literature on the prevalence and risk factors of NAFLD that are seen to be more common in the Latino population in the United States. Finally, we discuss available treatment options, medical and surgical, that are available for NAFLD and how they affect the Latino population. Health care providers need to address modifiable risk factors that impact the natural history as well as treatment outcomes for NAFLD among Latinos. Additional efforts are needed to improve awareness and health care utilization for Latinos.

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.

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.

Preoperative factors and 3-year weight change in the Longitudinal Assessment of Bariatric Surgery (LABS) consortium

BACKGROUND

Limited data guide the prediction of weight loss success or failure after bariatric surgery according to presurgery factors. There is significant variation in weight change after bariatric surgery and much interest in identifying preoperative factors that may contribute to these differences. This report evaluates the associations of a comprehensive set of baseline factors and 3-year weight change.

SETTING

Ten hospitals in 6 geographically diverse clinical centers in the United States.

METHODS

Adults undergoing a first bariatric surgical procedure as part of clinical care by participating surgeons were recruited between 2006 and 2009. Participants completed research assessments utilizing standardized and detailed data collection on over 100 preoperative and operative parameters for individuals undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB). Weight was measured 3 years after surgery. Percent weight change for RYGB or LAGB from baseline to 3 years was analyzed as both a continuous and dichotomous outcome with cut points at 25% for RYGB and 10% for LAGB. Multivariable linear and logistic regression models were used to identify independent baseline predictors of the continuous and categorical outcomes, respectively.

RESULTS

The median weight loss 3 years after surgery for RYGB (n = 1513) participants was 31.5% (IQR: 24.6%-38.4%; range, 59.2% loss to .9% gain) of baseline weight and 16.0% (IQR: 8.1%-23.1%; range, 56.1% loss to 12.5% gain) for LAGB (n = 509) participants. The median age was 46 years for RYGB and 48 years for LAGB; 80% of RYGB participants and 75% of LAGB participants were female; and the median baseline body mass index (BMI) was 46 kg/m(2) for RYGB and 44 kg/m(2) for LAGB. For RYGB, black participants lost 2.7% less weight compared with whites and participants with diabetes at baseline had 3.7% less weight loss at year 3 than those without diabetes at baseline. There were small but statistically significant differences in weight change for RYGB in those with abnormal kidney function and current or recent smoking. For LAGB participants, those with a large band circumference had 75% greater odds of experiencing less than 10% weight loss after adjusting for BMI and sex.

CONCLUSIONS

Few baseline variables were associated with 3-year weight change and the effects were small. These results indicate that baseline variables have limited predictive value for an individual's chance of a successful weight loss outcome after bariatric surgery.

TRIAL REGISTRATION

NCT00465829, ClinicalTrials.gov.

Ethnic variation in weight loss, but not co-morbidity remission, after laparoscopic gastric banding and Roux-en-Y gastric bypass

BACKGROUND

Demographic factors such as ethnicity may affect bariatric surgery outcomes. We examined weight loss and co-morbidities outcomes in African American, Caucasian, and Hispanic patients who underwent laparoscopic gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). The primary aim was to investigate demographic differences in weight loss and co-morbidities outcomes.

METHODS

We retrospectively examined weight change and co-morbidities outcomes in our prospective database. A total of 1,903 patients underwent LAGB or RYGB between January 1, 2005 and March 31, 2012. Of those, 1828 completed their 1-year follow-up visit (9-15 mo) and had complete data. We excluded patients who were missing ethnicity information, resulting in a final cohort of 1,684 patients. Multivariate analyses and χ2 tests were used to examine demographic variables in body mass index (BMI) change, percent excess weight loss (%EWL), and remission of co-morbidities. We also examined weight loss outcomes at 2- and 3-year follow-up.

RESULTS

Overall, those who underwent RYGB had a lower BMI and greater %EWL at 1, 2, and 3 years compared to those who had undergone LAGB. Overall, African American patients had a higher postoperative BMI than either Caucasian or Hispanic patients. African American patients also showed less %EWL than Caucasian and Hispanic patients. When we examined within surgery type, ethnic differences between African American and Caucasian patients were present across all 3 years in RYGB, but there were no ethnic differences by year 3 in LAGB. Additionally, African American and Hispanic patients no longer differed by year 3 in RYGB and by year 2 in LAGB. There were no significant ethnic differences in remission of diabetes, hyperlipidemia, hypertension, and sleep apnea at 1 year.

CONCLUSION

Our study found significant ethnic differences in the postoperative BMI and %EWL, which were more pronounced in patients undergoing RYGB than LAGB at the 3-year time point. These weight loss differences did not translate to a lower rate of co-morbidities remission.