Systematic Review and Meta-Analysis of the Effectiveness of Insurance Requirements for Supervised Weight Loss Prior to Bariatric Surgery

Social and Structural Determinants of Health and Social Injustices Contributing to Obesity Disparities

PURPOSE OF REVIEW: To analyze how social and structural determinants of health and social injustice impact the risk of obesity, its treatment and treatment outcomes, and to explore the implications for prevention and future treatment interventions. RECENT FINDINGS: Racial and ethnic minorities, such as non-Hispanic Black adults and Hispanic adults, and adults with a low socioeconomic status have a greater risk of obesity than non-Hispanic white adults and adults with a high socioeconomic status. The underlying causes of obesity disparities include obesogenic neighborhood environments, inequities in access to obesity treatment, and lack of access to affordable nutrient-dense foods. Experts have called for interventions that address the social and structural determinants of obesity disparities. Population-based interventions that focus on improving neighborhood conditions, discouraging the consumption of unhealthy foods and beverages, expanding access to obesity treatment, and ensuring equitable access to fruits and vegetables have been proven to be effective. There is a growing body of evidence that shows the relationship between social and structural determinants of health and injustice on disparities in obesity among racial and ethnic minorities and individuals with a low SES. Population-based, equity-focused interventions that address the underlying causes of obesity disparities are needed to reduce obesity disparities and improve the health outcomes of minoritized and marginalized groups.

Beyond race: social vulnerability and access to metabolic and bariatric surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) is under-accessed by non-White patients, who are disproportionately affected by obesity. We hypothesized that unique barriers experienced by socially vulnerable patients drive disparate MBS utilization.

OBJECTIVES

To determine whether socially vulnerable patients experience greater attrition and face more insurance-mandated medical weight management (MWM) requirements.

SETTING

Urban, academic center.

METHODS

This retrospective cohort study included adults evaluated for MBS in 2018. Social vulnerability was determined using the 2018 Social Vulnerability Index. Outcomes included attrition, or failure to undergo surgery within 1year, and the number and duration of MWM requirements. Multivariable logistic regression and negative binomial regression tested these associations.

RESULTS

In 2018, 339 patients were evaluated for MBS (83% female, 70% Black). The attrition rate was 57%. On adjusted analyses, patients in the highest social vulnerability quartile had double the odds of attrition compared to their least vulnerable counterparts (OR 2.33, 95% CI 1.11-4.92, P = .03). Highly vulnerable patients had double the number (IRR 2.29, 95% CI 1.42-3.72, P = .001) and nearly quadruple the duration (IRR 3.90, 95% CI 1.93-7.86, P < .001) of MWM requirements compared to those with low social vulnerability. Odds of attrition increased by 11% and 20% for each additional MWM visit (OR 1.11, 95% CI 1.02-1.20, P = .02) and month (OR 1.20, 95% CI 1.08-1.33, P = .001), respectively.

CONCLUSIONS

Patients with high social vulnerability were less likely to undergo MBS and faced more insurance-mandated preoperative requirements, which independently predicted attrition. Insurance-mandated MWM is inequitable and may contribute to disparate care of patients with severe obesity.

Addressing uncertainty about the role of structured lifestyle modification for metabolic surgery patients

There is good evidence that structured lifestyle modification programmes improve health in patients with metabolic and cardiovascular disorders, but there is no specific evidence that they improve outcomes in patients undergoing metabolic or obesity surgery. Despite expert consensus guidelines stating this fact, some healthcare systems still compel patients to participate in a structured lifestyle modification programme prior to metabolic or obesity surgery. There is a well-established need for individualised multidisciplinary dietetic and physical activity care for metabolic and obesity surgery patients, and the benefits of intentional weight loss prior to surgery are well proven, but these are distinct from potentially harmful requirements for patients to undertake compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery and reinforce obesity stigma. A critical step in rejuvenating metabolic surgery is to reframe patient participation in structured lifestyle modification programmes as an opportunity for education and empowerment, not as an indicator of motivation or suitability for metabolic surgery. Large, well-designed and adequately powered clinical trials are needed to address uncertainties in the evidence base for these programmes. Given genuine equipoise, they will need to determine whether "surgery plus lifestyle" is superior to "surgery plus placebo". Moreover, they will need to determine the cost-effectiveness of these programmes and identify some of the factors giving rise to the substantial heterogeneity in responses to structured lifestyle modification.

Preoperative Weight Gain Is Not Related to Lower Postoperative Weight Loss, But to Lower Total Weight Loss up to 3 Years After Bariatric-Metabolic Surgery

INTRODUCTION

Weight loss prior to bariatric-metabolic surgery (BMS) is recommended in most bariatric centers. However, there is limited high-quality evidence to support mandatory preoperative weight loss. In this study, we will evaluate whether weight gain prior to primary BMS is related to lower postoperative weight loss.

METHODS

A retrospective analysis of prospectively collected data was performed. Preoperative weight loss (weight loss from start of program to day of surgery), postoperative weight loss (weight loss from day of surgery to follow-up), and total weight loss (weight loss from start of program to follow-up) were calculated. Five groups were defined based on patients' preoperative weight change: preoperative weight loss of >5 kg (group I), 3-5 kg (group II), 1-3 kg (group III), preoperative stable weight (group IV), and preoperative weight gain >1 kg (group V). Linear mixed models were used to compare the postoperative weight loss between group V and the other four groups (I-IV).

RESULTS

A total of 1928 patients were included. Mean age was 44 years, 78.6% were female, and preoperative BMI was 43.7 kg/m2. Analysis showed significantly higher postoperative weight loss in group V, compared to all other groups at 12, 24, and 36 months follow-up. Up to three years follow-up, highest total weight loss was observed in group I.

CONCLUSION

Weight gain before surgery should not be a reason to withhold a bariatric-metabolic operation. However, patients with higher preoperative weight loss have higher total weight loss. Therefore, preoperative weight loss should be encouraged prior to bariatric surgery.

Impact of Treatment with GLP1 Receptor Agonists, Liraglutide 3.0 mg and Semaglutide 1.0 mg, While on a Waiting List for Bariatric Surgery

BACKGROUND

Weight loss before undergoing metabolic and bariatric surgery (MBS) has been suggested to reduce perioperative complications, although with controversial results. The objective of this study is to evaluate the impact of treatment with GLP1-R agonists (liraglutide 3.0 mg and semaglutide 1.0 mg) on preoperative weight loss and patients' decisions regarding MBS while on a surgical waiting list.

MATERIALS AND METHODS

One hundred and two patients on a waiting list for MBS started treatment with GLP1-RA for at least 6 months. Changes in weight at 26 and 52 weeks, the number of patients achieving >5% weight loss, and patients' decisions regarding MBS were evaluated.

RESULTS

After 52 weeks, patients lost 16.9 ± 7.2% of weight with semaglutide 1.0 mg and 16.1 ± 5.8% of weight with liraglutide 3.0 mg. All patients lost ≥5% of initial weight, 84.7% lost ≥10%, 54.6% lost ≥15%, and 27.5% reached ≥20%. A total of 68.6% of participants were satisfied with the achieved weight loss and withdrew from the waiting list for MBS. A threshold of >15.1% weight loss had the greatest sensitivity and specificity for the final decision regarding undergoing MBS.

CONCLUSIONS

Losing >15% of initial weight after 52 weeks of treatment with liraglutide 3.0 mg or semaglutide 1.0 mg during the waiting list for MBS impacts patients' decisions regarding the final acceptance or rejection of the procedure.

Barriers to Bariatric Surgery: a Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery

PURPOSE

Populations most affected by obesity are not reflected in the patients who undergo bariatric surgery. Gaps in the referral system have been studied, but there is a lack of literature investigating obstacles patients encounter after first contact with bariatric surgery clinics. We aim to identify patient populations at risk for attrition during bariatric surgery evaluation and determine patient reported barriers to bariatric surgical care.

MATERIALS AND METHODS

This study was a single institution, retrospective, mixed methods study from 2012 to 2021 comparing patients who underwent bariatric surgery to those that withdrew. Surveys were performed of patients who withdrew, collecting information on patient knowledge, expectations, and barriers.

RESULTS

This study included 5982 patients evaluated in bariatric surgery clinic. Those who attained bariatric surgery (38.8%) were more likely to be White (81.2 vs. 75.6%, p<0.001), married (48.5 vs. 44.1%, p=0.004), and employed full time (48.2 vs. 43.8%, p=0.01). They were less likely to live in an area with low income (37.1 vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 vs. 17.4, p<0.001). Of the 280 survey respondents, fear of complications, length of insurance approval process, and wait time between evaluation and surgery were the most reported barriers.

CONCLUSION

Patients who undergo bariatric surgery were more likely to be White, married, employed full time, and reside in more resourced environments which is not reflective of communities most affected by obesity. The complexity of insurance coverage requirements was a major barrier to bariatric surgery and should be a focus of future healthcare reform.

Do Lifestyle Interventions before Gastric Bypass Prevent Weight Regain after Surgery? A Five-Year Longitudinal Study

It is unclear whether weight loss (WL) achieved by means of lifestyle interventions (LSIs) before bariatric surgery (BS) can improve long-term WL outcomes after surgery. We aimed to assess the impact of a structured LSI on WL% after gastric bypass (GBP). Two groups of patients were selected from a large cohort of participants with obesity who underwent GBP surgery at Santa Maria Nuova Hospital (Reggio Emilia, Italy). The groups were categorized as those who have or have not received LSI prior to GBP. The LSI group included 91 participants (cases) compared to 123 participants (controls) in the non-LSI group. WL% was measured at follow-up times of 1, 3, 6, 12, 24, 36, 48, and 60 months. The LSI group achieved a clinically significant WL% (−7.5%) before BS, and at the time of surgery, the two groups had similar body weights and demographic statuses. At all points, until the 24-month follow-up, the two groups displayed similar WLs%. With regard to the longer follow-ups, the LSI group maintained weight loss until the last timepoint (60 months), whereas the non-LSI group experienced weight regain at 36, 48, and 60 months. In a real-world context, a structured behavioral LSI prior to GBP seems to prevent longer-term weight regain.