Pursuing bariatric surgery in an urban area: Gender and racial disparities and risk for psychiatric symptoms

Suicide attempts after bariatric surgery: comparison to a nonsurgical cohort of individuals with severe obesity

BACKGROUND

The rate of suicide is higher among individuals following bariatric surgery compared with the general population; however, it is not clear whether risk is associated with bariatric surgery beyond having severe obesity.

OBJECTIVE

To compare the risk of a suicide attempt among those who had bariatric surgery versus a nonsurgical cohort with severe obesity.

SETTING

Aggregate count data were collected from 5 healthcare systems.

METHODS

Individuals were identified in the surgical cohort if they underwent bariatric surgery between 2009 and 2017 (n = 35,522) and then were compared with a cohort of individuals with severe obesity who never had bariatric surgery (n = 691,752). Suicide attempts were identified after study enrollment date using International Classification of Diseases, Ninth and Tenth Editions (ICD-9 and ICD-10) diagnosis codes from 2009 to 2021.

RESULTS

The relative risk of a suicide attempt was 64% higher in the cohort with bariatric surgery than that of the nonsurgical cohort (2.2% versus 1.3%; relative risk = 1.64; 95% CI, 1.53-1.76). Within the cohort with bariatric surgery, suicide attempts were more common among the 18- to 39-year age group (P < .001), women (P = .002), Hawaiian-Pacific Islanders (P < .001), those with Medicaid insurance (P < .001), and those with a documented mental health condition at baseline (in the previous 2 years; P < .001).

CONCLUSIONS

The relative risk of suicide attempts was higher among those who underwent bariatric surgery compared with a nonsurgical cohort, though absolute risk remained low. Providers should be aware of this increased risk. Screening for suicide risk after bariatric surgery may be useful to identify high-risk individuals.

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.

Depression and Anxiety as Predictors of Metabolic and Bariatric Surgery Completion Among Ethnically Diverse Patients

BACKGROUND

Mental health conditions including depression and anxiety are often prevalent among metabolic and bariatric surgery (MBS) patients, but it is not known if these conditions predict the decision to complete the procedure and if this varies by race and ethnicity. This study aimed to determine if depression and anxiety are associated with MBS completion among a race/ethnically diverse sample of patients.

METHODS

This prospective cohort study included participants who were referred to an obesity program or two MBS practices between August 2019 and October 2022. Participants completed the Mini International Neuropsychiatric Interview (MINI) instrument to determine history of anxiety and/or depression, as well as MBS completion status (Y/N). Multivariable logistic regression models determined the odds of MBS completion by depression and anxiety status adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

The sample consisted of 413 study participants (87 % women, 40% non-Hispanic White, 39% non-Hispanic Black, and 18% Hispanic). Participants with a history of anxiety were less likely to complete MBS (aOR = 0.52, 95% CI = 0.30-0.90, p = 0.020). Women had increased odds of a history of anxiety (aOR = 5.65, 95% CI = 1.64-19.49, p = 0.006) and of concurrent anxiety and depression (aOR = 3.07, 95% CI = 1.39-6.79, p = 0.005) compared to men.

CONCLUSIONS

Results showed that participants with anxiety were 48% less likely to complete MBS compared to those without anxiety. Additionally, women were more likely to report a history of anxiety with and without depression versus men. These findings can inform pre-MBS programs about risk factors for non-completion.

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.

Characteristics and resolution of hypertension in obese African American bariatric cohort

Weight reduction continues to be first-line therapy in the treatment of hypertension (HTN). However, the long-term effect of bariatric malabsorptive surgical techniques such as Roux-en-Y Gastric Bypass (RYGB) surgery in the management of hypertension (HTN) is less clear. African Americans (AA) are disproportionately affected by obesity and hypertension and have inconsistent outcomes after bariatric surgery (BS). Despite a plethora of bariatric literature, data about characteristics of a predominantly AA bariatric hypertensive cohort including hypertension in obese (HIO) are scarce and underreported. The aims of this study were, (1) to describe the preoperative clinical characteristics of HIO with respect to HTN status and age, and (2) to identify predictors of HTN resolution one year after RYGB surgery in an AA bariatric cohort enrolled at the Howard University Center for Wellness and Weight Loss Surgery (HUCWWS). In the review of 169 AA bariatric patients, the average BMI was 48.50 kg/m2 and the average age was 43.86 years. Obese hypertensive patients were older (46 years vs. 37.89 years; p < .0001); had higher prevalence of diabetes mellitus (DM, 43.09% vs. 10.87%; p < .0001) and dyslipidemia (38.2% vs. 13.04%; p 0.002). Hypertensive AA who were taking ≥ 2 antihypertensive medications prior to RYGB were 18 times less likely to experience HTN resolution compared to hypertensive AA taking 0-1 medications, who showed full or partial response. Also, HIO was less likely to resolve after RYGB surgery in patients who needed ≥ 2 antihypertensive medications prior to surgical intervention.

Characteristics and resolution of hypertension in obese African American bariatric cohort

Weight reduction continues to be first-line therapy in the treatment of hypertension (HTN). However, the long-term effect of bariatric malabsorptive surgical techniques such as Roux-en-Y Gastric Bypass (RYGB) surgery in the management of hypertension (HTN) is less clear. African Americans (AA) are disproportionately affected by obesity and hypertension and have inconsistent outcomes after bariatric surgery (BS). Despite a plethora of bariatric literature, data about characteristics of a predominantly AA bariatric hypertensive cohort including hypertension in obese (HIO) are scarce and underreported. The aims of this study were, (1) to describe the preoperative clinical characteristics of HIO with respect to HTN status and age, and (2) to identify predictors of HTN resolution one year after RYGB surgery in an AA bariatric cohort enrolled at the Howard University Center for Wellness and Weight Loss Surgery (HUCWWS). In the review of 169 AA bariatric patients, the average BMI was 48.50 kg/m2 and the average age was 43.86 years. Obese hypertensive patients were older (46 years vs. 37.89 years; p < .0001); had higher prevalence of diabetes mellitus (DM, 43.09% vs. 10.87%; p < .0001) and dyslipidemia (38.2% vs. 13.04%; p 0.002). Hypertensive AA who were taking ≥ 2 antihypertensive medications prior to RYGB were 18 times less likely to experience HTN resolution compared to hypertensive AA taking 0-1 medications, who showed full or partial response. Also, HIO was less likely to resolve after RYGB surgery in patients who needed ≥ 2 antihypertensive medications prior to surgical intervention.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry

Background

The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients.

Methods

The MBSAQIP database was reviewed for RYGB and SG patients (2015–2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes.

Results

After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak.

Conclusion

African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Partnering Support Interventions with Bariatric Surgery to Maximize Health Outcomes in Adolescents with Severe Obesity

OBJECTIVE

Rates of adolescents with severe obesity continue to rise worldwide, with concurrent increases in metabolic and bariatric surgery (MBS) uptake. The gap between support (lifestyle, pharmacotherapy) interventions and MBS as treatment options for adolescents has been understudied. This review, couched in a socio-ecological framework, investigates how support interventions for adolescents with severe obesity could be combined or sequenced with MBS to optimize health outcomes.

METHODS

A comprehensive search revealed 36 published articles between 1995 and 2019 that included the combination of support interventions and MBS among adolescents.

RESULTS

There were no studies that specifically reported outcomes or effect sizes for the combination of lifestyle intervention with MBS. Previous studies have reported individual results for either lifestyle intervention or MBS but not for their compound effect.

CONCLUSIONS

As rates of adolescents with severe obesity are on the rise globally, future research should focus on how partnering support interventions with MBS can amplify positive short- and long-term health outcomes and within a socio-ecological framework. Understanding the sequence of these approaches will be of particular importance. High-risk and vulnerable populations such as ethnic minorities who have suffered a disproportionate burden of the obesity epidemic must be included in rigorously tested future trials of combination interventions to maximize health outcomes worldwide.

An Investigation of Racial Disparities in Weight Loss Outcomes: Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy

OBJECTIVE

The current study aimed to test if racial disparities in weight loss outcomes between African American and Caucasian patients who underwent bariatric surgery were due to pre-surgical BMI differences.

METHODS

Primary data was collected from pre-surgical evaluations conducted at a midwestern hospital. A retrospective chart review was conducted of 136 patients. Patient age and race, type of procedure, and pre- and 1-year post-surgical BMI were collected.

RESULTS

African American patients were less likely to undergo bariatric surgery compared with Caucasian patients. Caucasian patients undergoing Roux-en-Y Gastric Bypass (RYGB) had a greater change in BMI compared with African American patients who underwent RYGB. Significant differences in weight loss outcomes were not found among patients who underwent the sleeve gastrectomy. Race was not related to pre-surgical BMI or procedure type.

CONCLUSION

Despite pre-surgical BMI typically being higher among African American patients, this was not found in the current study. Pre-surgical BMI may not explain the racial disparities in weight loss post-bariatric surgery that are found between African American and Caucasian patients. Future studies should consider psychosocial, environmental, and cultural influences on racial disparities.

Mental health quality of life after bariatric surgery: A systematic review and meta-analysis of randomized clinical trials

Recent literature has raised concerns regarding the risk of adverse psychiatric events among bariatric surgery patients. However, the relationship between weight loss therapy and psychiatric outcomes is confounded by baseline psychosocial characteristics in observational studies. To understand the impact of bariatric surgery on the risk of adverse mental health outcomes, we conducted a systematic review and meta-analysis of randomized controlled trials that compared surgical and non-surgical treatments and assessed mental health quality of life (QoL). We evaluated the PubMed, EMBASE, Web of Science PsycINFO, Clinicaltrials.gov and Cochrane databases through 7 March 2018. Pooled standardized mean differences (SMDs) for mental health QoL scores were estimated using random effects models. Eleven randomized trials with 731 participants were included in the final analyses. Surgery was not associated with an improvement in mental health QoL from baseline as compared to non-surgical intervention (SMD: 0.02, 95% confidence interval [CI] -0.22 to 0.25). Final mental health QoL scores were similar for surgically and non-surgically treated patients (SMD: 0.37, 95% CI -0.07 to 0.81). Subgroup analyses assessing the effect of specific surgical interventions, and varying lengths of follow-up did not identify a beneficial effect of bariatric surgery on mental health QoL outcomes. These results, in conjunction with the fact that individuals who choose bariatric surgery tend to have high-risk baseline characteristics, suggest that intensive mental health follow-up following surgery should be routinely considered.

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.

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.