Bariatric Surgery, Clinical Outcomes, and Healthcare Burden in Hispanics in the USA

Supervised weight loss requirements disproportionately affect Black patients seeking weight loss surgery

BACKGROUND

We use our high-volume institutional experience with a majority Black population to examine the role of supervised weight loss (SWL) requirements perpetuating disparities in bariatric surgery.

OBJECTIVE

To determine if there are racial disparities in the required amount of supervised weight loss prior to approval for bariatric surgery.

SETTING

University hospital.

METHODS

A retrospective review was conducted of all patients seen at our institution's bariatric surgery clinic in 2018. Odds of undergoing surgery within 1 year and mean number of SWL requirements were determined using descriptive statistics for Black patients as compared with non-Hispanic White patients. Finally, a logistic model was constructed to examine likelihood of undergoing an operation within 1 year for patients of varying SWL requirements.

RESULTS

A total of 335 patients were included (75% Black, 25% White). Within 1 year, 37% of Black patients compared with 53% of White patients had undergone an operation (relative risk .7, P = .01). Mean insurance-mandated SWL sessions were significantly higher for Black patients (3.6 ± 2.8) versus non-Hispanic White patients (2.2 ± 2.7) (P < .01). Mean program-mandated SWL sessions were also significantly higher for Black patients (2.5 ± 2.6) versus non-Hispanic White patients (.8 ± 1.8) (P < .01). Increasing SWL requirements significantly reduced the odds of undergoing surgery at 1 year within the entire cohort (odds ratio .86, P < .01).

CONCLUSIONS

Black patients are disproportionally affected by SWL requirements, which strongly correlate with decreased likelihood of undergoing a bariatric operation as compared with their White counterparts. Even after overcoming barriers to see a bariatric surgery provider, Black patients still face disproportionally more barriers to surgery. Bariatric centers must be sensitive to the effect of SWL requirements, as it is negatively associated with the likelihood of a patient receiving a bariatric operation.

A study analyzing outcomes after bariatric surgery by primary language

BACKGROUND

Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language.

METHODS

This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race.

RESULTS

Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes.

CONCLUSIONS

Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Spanish-language bariatric surgery patient education materials fail to meet healthcare literacy standards of readability

BACKGROUND

The Hispanic population is the fastest growing ethnic minority in the United States, contributing to nearly half of the population growth over the last decade. Unfortunately, this population suffers from lower-than-average health literacy rates, leading to poorer health outcomes. Per the American Medical Association and National Institutes of Health, patient education materials (PEMs) should be written at no higher than a 6th grade reading level. Given that US Hispanic adults have the second-highest obesity prevalence, this study aims to analyze the readability of Spanish-language PEMs regarding bariatric surgery available in US-based academic and medical centers.

METHODS

A total of 50 PEMs were found via the query ""cirugía de pérdida de peso" site: (edu OR.org)" on the Google search engine. Thirty-nine sources met the inclusion criteria of belonging to a US-based academic or medical center and containing information regarding the indications for bariatric surgery, descriptions of the types of bariatric surgery, what to expect before and after surgery, or the risks and benefits of bariatric surgery. The excerpts were analyzed according to three readability formulas designed specifically for the Spanish language and evaluated for their reading grade level.

RESULTS

All 39 sources were at the college reading level per the Fry graph corrected for Spanish. Per the Spaulding formula, 37 sources were "Grade 12 + " and two sources were "Grade 8-10." Per the Fernandez-Huerta formula, 16 sources were at the 8th/9th grade reading level, 22 sources were at the 7th grade reading level, and one was at the 6th grade reading level.

CONCLUSION

The Spanish-language bariatric surgery PEMs available online from US-based academic and medical centers are generally above the recommended 6th grade reading level. Failure to meet the recommended sixth-grade reading level decreases health care literacy for Spanish-speaking patients within the United States seeking bariatric surgery.

A Call to Reconceptualize Obesity Treatment in Service of Health Equity: Review of Evidence and Future Directions

PURPOSE OF REVIEW

Rates of obesity and associated comorbidities are higher among Black and Latino adults compared to white adults. We sought to provide an overview of both structural and individual factors contributing to obesity inequities and synthesize available evidence regarding treatment outcomes in Black and Latino adults, with an eye towards informing future directions.

RECENT FINDINGS

Obesity disparities are influenced by myriad systemic issues, yet the vast majority of interventions target individual-level factors only, and most behavioral treatments fail to target drivers beyond eating and physical activity. Extant treatments are not equally accessible, affordable, or effective among Black and Latino adults compared with white counterparts. Asset-based, culturally relevant interventions that target the root causes of obesity and address intersectional stress-designed in partnership with intended beneficiaries-are urgently needed. Treatment trials must improve enrollment of Black and Latino adults and report treatment outcomes by race and ethnicity.

Obesity among Latinx people in the United States: A review

Obesity is a serious, chronic disease that is associated with a range of adiposity-based comorbidities, including cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease. In the United States, obesity is a public health crisis, affecting more than 40% of the population. Obesity disproportionately affects Latinx people, who have a higher prevalence of obesity and related comorbidities (such as cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease) compared with the general population. Many factors, including genetic predisposition, environmental factors, traditional calorie-dense Latinx diets, family dynamics, and differences in socioeconomic status, contribute to the increased prevalence and complexity of treating obesity in the Latinx population. Additionally, significant heterogeneity within the Latinx population and disparities in health care access and utilization between Latinx people and the general population add to the challenge of obesity management. Culturally tailored interventions have been successful for managing obesity and related comorbidities in Latinx people. Antiobesity medications and bariatric surgery are also important options for obesity treatment in Latinx people. As highlighted in this review, when managing obesity in the Latinx population, it is critical to consider the impact of genetic, dietary, cultural, and socioeconomic factors, in order to implement an individualized treatment strategy.

How much abdominal fat do obese patients lose short term after laparoscopic sleeve gastrectomy? A quantitative study evaluated with MRI

Background

This study aimed to elucidate the changes in the amount of abdominal adipose tissue after laparoscopic sleeve gastrectomy in obese Chinese patients over a relatively short follow-up period and to analyze the differences in the effects of surgery between genders.

Methods

Ninety-one patients were enrolled in the study, including 18 males and 73 females. These patients underwent laparoscopic sleeve gastrectomy between November 2017 and November 2019. Before and short term after surgery, the areas of subcutaneous/visceral adipose tissue and the liver proton density fat fraction were calculated with upper abdominal magnetic resonance (MR) examinations.

Results

Approximately 100 days after surgery, the median values of weight loss and body mass index reduction were 23.1 kg and 8.1 kg/m², respectively. The patients achieved a greater absolute loss of subcutaneous adipose tissue index than of visceral adipose tissue index (3.2×10^-3 vs. 1.6×10^-3, P<0.001). The amount of weight loss, body mass index loss and absolute/relative reduction in visceral adipose tissue index were much greater in males than in females (31.7 vs. 21.7 kg, P<0.001; 9.8 vs. 7.9 kg/m², P=0.016; 2.5×10^-3 vs. 1.3×10^-3, P=0.007; 28.2% vs. 20.9%, P=0.029). There was a correlation between decreased amounts in subcutaneous and visceral adipose tissue in sum and weight loss (r=0.282, P=0.032). The absolute/relative reduction in visceral adipose tissue index was also correlated with absolute/relative reduction in liver proton density fat fraction (r=0.283, P=0.013; r=0.372, P=0.001).

Conclusions

The reductions in body weight and visceral fat were more significant in male patients. The sum of absolute reduction in subcutaneous and visceral fat deposits was correlated with weight loss, in all patients enrolled. For severely obese patients, an upper abdominal MR examination could assess the body tissue composition and how it changes after bariatric surgery.

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

Obesity, Hypertension, and Bariatric Surgery

PURPOSE OF REVIEW

Obesity increases the risk of hypertension. However, blood pressure decreases before any significant loss of body weight after bariatric surgery. We review the mechanisms of the temporal dissociation between blood pressure and body weight after bariatric surgery.

RECENT FINDINGS

Restrictive and bypass bariatric surgery lower blood pressure and plasma leptin levels within days of the procedure in both hypertensive and normotensive morbidly obese patients. Rapidly decreasing plasma leptin levels and minimal loss of body weight point to reduced sympathetic nervous system activity as the underlying mechanism of rapid blood pressure decline after bariatric surgery. After the early rapid decline, blood pressure does not decrease further in patients who, while still obese, experience a steady loss of body weight for the subsequent 12 months. The divergent effects of bariatric surgery on blood pressure and body weight query the role of excess body weight in the pathobiology of the obesity phenotype of hypertension. The decrease in blood pressure after bariatric surgery is moderate and independent of body weight. The lack of temporal relationship between blood pressure reduction and loss of body weight for 12 months after sleeve gastrectomy questions the nature of the mechanisms underlying obesity-associated hypertension.