Risk perception of obesity and bariatric surgery in patients seeking treatment for obesity

A machine learning framework for optimizing obesity care by simulating clinical trajectories and targeted interventions

OBJECTIVE

This study aimed to determine the important clinical management bottlenecks that contribute to underuse of weight loss surgery (WLS) and assess risk factors for attrition at each of them.

METHODS

A multistate conceptual model of progression from primary care to WLS was developed and used to study all adults who were seen by a primary care provider (PCP) and eligible for WLS from 2016 to 2017 at a large institution. Outcomes were progression from each state to each subsequent state in the model: PCP visit, endocrine weight management referral, endocrine weight management visit, WLS referral, WLS visit, and WLS.

RESULTS

Beginning with an initial PCP visit, the respective 2-year Kaplan-Meier estimate for each outcome was 35% (n = 2063), 15.6% (n = 930), 6.3% (n = 400), 4.7% (n = 298), and 1.0% (n = 69) among 5876 eligible patients. Individual providers and clinics differed significantly in their referral practices. Female patients, younger patients, those with higher BMI, and those seen by trainees were more likely to progress. A simulated intervention to increase referrals among PCPs would generate about 49 additional WLS procedures over 3 years.

CONCLUSIONS

This study discovered novel insights into the specific dynamics underlying low WLS use rates. This methodology permits in silico testing of interventions designed to optimize obesity care prior to implementation.

Patient and the Public's Perceptions of Bariatric Surgery: A Systematic Review

INTRODUCTION

Bariatric surgery is an effective therapeutic modality for obesity and related comorbidities, yet it remains significantly underutilized. Patient perceptions and expectations may influence the decisions of eligible patients in pursuing surgery.

METHODS

PubMed, SCOPUS, and OVID databases were searched in July 2022 to identify published studies discussing patient and the public's perceptions of bariatric surgery.

RESULTS

The literature shows participants often reported bariatric surgery to be a life-changing intervention known to induce weight loss, improve obesity-related comorbidities, and improve quality of life. However, a significant proportion of survey respondents perceived bariatric surgery as unsafe or risky. Patients belonging to racial minority groups cited higher concern with mortality risk, lower weight loss expectations, and different motivations to pursue bariatric surgery. Female patients were significantly more likely to have more positive perceptions of, and higher expectations of weight loss from, bariatric surgery.

CONCLUSIONS

The literature highlighted discordance between patient perceptions and the demonstrated clinical safety and efficacy profile of bariatric surgery. Overestimations of the risks, unrealistic expectations, and unfamiliarity with bariatric surgery outcomes were common findings. These perceptions of bariatric surgery may contribute to its underutilization among eligible patients. Perceptions and motivations often varied by race, region, sex, and age, which demonstrates the necessity of patient-centered education in the prereferral stage. The literature also demonstrated misconceptions of bariatric surgery among the public. Further research should explore the impact of education on the perceptions of patients and the public.

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment

The prevalence of class 3 obesity (body mass index ≥40 kg/m²) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate.

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction

BACKGROUND

Perioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery.

OBJECTIVES

To enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool.

SETTING

Bariatric surgery centers, United States.

METHODS

Patients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016.

RESULTS

We identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4-21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2-11.4), hyperlipidemia (OR = 2.60, CI = 1.3-5.1), and age >50 (OR = 2.15, CI = 1.1-4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5.

CONCLUSION

The prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.

Efficacy of video-based education program in improving metabolic surgery perception among patients with obesity and diabetes

BACKGROUND

Metabolic surgery remains underutilized despite its efficacy and safety. Poor perception of surgery has been cited as one of the major reasons.

OBJECTIVES

Evaluate current patient perceptions about metabolic surgery and measure the impact a video-based education program has on changing the perceptions of patients diagnosed with obesity and type 2 diabetes.

SETTING

A university hospital in the United States.

METHODS

A prospective interventional study was performed at an endocrinology clinic. Patients were asked to complete surveys evaluating their perception of metabolic surgery before and after watching a short educational video.

RESULTS

A total of 51 patients were recruited; almost all patients (98%) attempted weight loss in the past, and approximately 90.1% voiced dissatisfaction with their current weight. The video-based education program was effective in improving the patient's perception of the efficacy and safety with regard to surgery. In addition, the proportion of patients with overall positive impression toward metabolic surgery increased from 22.5% to 53.1% (P < .01) and those willing to undergo surgical consultation increased from 41.7% to 51.0% (P < .01). Among those that remained unwilling, fear of surgery in general was the most commonly voiced reason (31.4%), with safety (27.5%) and cost of metabolic surgery (27.5%) being equally concerning.

CONCLUSIONS

Most patients with obesity and type 2 diabetes held negative impressions of metabolic surgery due to its perceived risk profile. A video-based educational intervention may improve patients' perception and increase their willingness for surgical referral. Future trials with a broader sample and longer follow-up could provide answers to its efficacy in increasing metabolic surgery accessibility.

Patient preferences and bariatric surgery procedure selection; the need for shared decision-making

BACKGROUND

Bariatric surgery is the most effective treatment for patients suffering from obesity-related comorbidities. There is little data regarding how patients choose one particular bariatric procedure over another. This study aimed to better define the relationship between preferences of patients considering bariatric surgery and the procedure patients undergo.

METHODS

A bilingual questionnaire was administered to all prospective patients seen between March 1 and August 31, 2012. The questionnaire assessed basic knowledge of bariatric surgery (based on the information seminar) as well as patient preferences of the various outcomes and complications for sleeve gastrectomy, gastric bypass, and gastric banding.

RESULTS

One hundred seventy-two patients completed the questionnaire. Fifty-eight percent of patients chose "maximum weight loss" as the most important outcome, and 65 % chose "leak" as the most concerning complication. Subgroup analysis of patients with diabetes revealed that 58 % chose "curing diabetes" as the most important outcome. Nineteen percent of patients were either not sure which procedure they wanted or changed their decision after consultation with the surgeon.

CONCLUSIONS

The decision to choose one bariatric procedure over another is complex and is based on factors beyond absolute patient preferences. Although maximum weight loss is a commonly reported preference for patients seeking bariatric surgery, patients with diabetes are more focused on diabetes remission. Most patients have already decided which procedure to undergo prior to surgeon consultation. Patients may benefit from shared decision making, which integrates patient values and preferences along with current medical evidence to assist in the complex bariatric surgery selection process.

US adults recommended for weight reduction by 1998 and 2013 obesity guidelines, NHANES 2007-2012

OBJECTIVE

To determine the number and proportion of American adults recommended for weight loss treatment under the 1998 and 2013 guidelines on the management of overweight and obesity in adults and to compare characteristics of individuals recommended for treatment.

METHODS

A total of 6,692 adult, non-pregnant participants in the National Health and Nutrition Examination Survey 2007-2012 with complete data on demographics, anthropometrics, and biomedical measures were analyzed.

RESULTS

Compared to the 1998 guidelines, the 2013 guidelines increased the number of adults recommended for weight loss treatment by 20.9% from 116.0 million to 140.2 million, making 64.5% of non-pregnant, non-institutionalized US adults candidates for treatment. The new guidelines recommended treatment for a larger proportion of those overweight, having only one risk factor, or having a large waist circumference. Up to 53.4% of adults could be considered for pharmacologic therapy in addition to lifestyle therapy, and up to 14.7% could be considered for bariatric surgery.

CONCLUSIONS

The 2013 guidelines increased the number of adults to be treated with weight loss by 24.2 million, with the increases spread across groups that differ in socio demographic characteristics.

Aspirin overutilization for the primary prevention of cardiovascular disease

Background

Aspirin is commonly used for the primary prevention of cardiovascular disease (CVD) in the US. Previous research has observed significant levels of inappropriate aspirin use for primary CVD prevention in some European populations, but the degree to which aspirin is overutilized in the US remains unknown. This study examined the association between regular aspirin use and demographic/clinical factors in a population-based sample of adults without a clinical indication for aspirin for primary prevention.

Methods

A cross-sectional analysis was performed using 2010–2012 data from individuals aged 30–79 years in the Marshfield Epidemiologic Study Area (WI, USA). Regular aspirin users included those who took aspirin at least every other day.

Results

There were 16,922 individuals who were not clinically indicated for aspirin therapy for primary CVD prevention. Of these, 19% were regular aspirin users. In the final adjusted model, participants who were older, male, lived in northern Wisconsin, had more frequent medical visits, and had greater body mass index had significantly higher odds of regular aspirin use (P<0.001 for all). Race/ethnicity, health insurance, smoking, blood pressure, and lipid levels had negligible influence on aspirin use. A sensitivity analysis found a significant interaction between age and number of medical visits, indicating progressively more aspirin use in older age groups who visited their provider frequently.

Conclusion

There was evidence of aspirin overutilization in this US population without CVD. Older age and more frequent provider visits were the strongest predictors of inappropriate aspirin use. Obesity was the only significant clinical factor, suggesting misalignment between perceived aspirin benefits and cardiovascular risks in this subgroup of patients. Prospective studies that examine cardiac and bleeding events associated with regular aspirin use among obese samples (without CVD) are needed to refine clinical guidelines in this area.

Patient factors associated with undergoing laparoscopic adjustable gastric banding vs Roux-en-Y gastric bypass for weight loss

BACKGROUND

Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are 2 commonly performed bariatric procedures in the US with different profiles for risk and effectiveness. Little is known about factors that might lead patients to proceed with one procedure over the other.

STUDY DESIGN

We recruited and interviewed patients seeking bariatric surgery from 2 academic centers in Boston (response rate 70%). We conducted multivariable analyses to identify patient perceptions and clinical and behavioral characteristics that correlated with undergoing gastric banding (n = 239) vs gastric bypass (n = 297).

RESULTS

After adjustment for socio-demographic and clinical factors, we found that older patients (odds ratio [OR] 1.03; 95% CI 1.00 to 1.05) and those with higher quality of life scores and higher levels of uncontrolled eating were more likely to undergo gastric banding as opposed to gastric bypass. In contrast, patients with type 2 diabetes (OR 0.46; 95% CI 0.28 to 0.77), those who desired greater weight loss, and those who were willing to assume higher mortality risk to achieve their ideal weight were less likely to proceed with gastric banding. After initial adjustment, male sex and lower body mass index were associated with a likelihood of undergoing gastric banding; however, these factors were no longer significant after adjustment for other significant correlates such as patients' perceived ideal weight, predilection to assume risk to lose weight, and eating behavior.

CONCLUSIONS

Patients' diabetes status, quality of life, eating behavior, ideal weight loss, and willingness to assume mortality risk to lose weight were associated with whether patients proceeded with gastric banding as opposed to gastric bypass. Other clinical factors were less important.