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CME Author: Zeena Nackerdien

Study Authors: Michael H.Wood, Arthur M. Carlin, et al.

Target Audience and Goal Statement:

Bariatric surgeons, gastroenterologists, weight loss specialists, endocrinologists, internists

The goal of the study was to examine the association of race on perioperative and 1-year outcomes of bariatric surgery.

Question Addressed:

• How is race associated with the safety and effectiveness of bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding)?

Synopsis and Perspective:

After bariatric surgery, black patients faced worse outcomes than white patients for 30-day complications, resource utilization, and weight loss at 1 year, according to a retrospective analysis of over 7,100 bariatric surgery patients from Michigan.

Only and 5% of children were regarded as obese during the late '70s. Today, of U.S. adults and 18.5% of children are considered obese. Based on 2013-2014 National Health and Nutrition Examination Survey (NHANES) data, obesity disproportionately affected African-American men and women (non-Hispanic black men vs non-Hispanic white men: 38% vs 34.7%; non-Hispanic black women vs non-Hispanic white women: 57.2% vs 38.2%).

"Today Show" host Al Roker's , including gastric bypass surgery, served as one of many inspirational stories to increasingly overweight Americans. If dieting and exercise worked for everyone, there would be no , which worked for Roker. But there is evidence that weight loss and comorbidity remission appear to vary considerably across patients and procedures.

While all races benefited from bariatric surgery, showed that weight and comorbidity burden declined less among blacks compared to whites. Other studies yielded mixed results, highlighting the need for more extensive analysis of the association of race with outcomes after bariatric surgery.

Jonathan Finks, MD, of the University of Michigan Health Systems in Ann Arbor, and colleagues measured 30-day complications and healthcare resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction among propensity-matched black (n=7,105) and white patients (n=7,105) who underwent bariatric surgeries (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding).

Baseline characteristics between the groups were well-balanced, except for income and type of surgery. About 14.9% of black patients earned more than $75,000 versus 15.7% of white patients. A higher proportion of black patients underwent gastric bypass or sleeve gastrectomy procedures, while more white patients opted for adjustable gastric banding.

Rates of any complication at 30 days were higher among blacks versus whites (8.8% vs 6.8%, adjusted odds ratio 1.33). However, there were no significant differences in the rates of serious complications or mortality. More prolonged hospital stays (mean 2.2 vs 1.9 days, adjusted OR 0.3), readmissions (5.8% vs 3.5%, adjusted OR 1.73), and emergency departments (11.6% vs 7.6%, adjusted OR 1.6) were also disproportionately associated with black patients.

Compared with white patients, black patients had lower mean total body weight loss across procedures (32 kg vs 38.3 kg) at 1 year. Higher remission of sleep apnea (62.6% vs 56.1%) and gastroesophageal disease (78.6% vs 75.4%) were observed among blacks over the same time period, but significantly lower remission was seen for hypertension (40% vs 56%, P<0.001). However, remission rates for diabetes with or without insulin dependence and hyperlipidemia did not differ between races.

Less black patients than white patients reported a good or very good quality of life (87.2% vs 90.4%), and being very satisfied with surgery (78.4% vs 84.2%).

Study limitations included the fact that disease duration and/or severity may have been greater in black patients, potentially altering the results, according to the authors. Adverse events were captured by the Michigan Bariatric Surgery Collaborative within 30 days of the index operation. Using a wider time horizon may have led to altered results. Quality of life and satisfaction scores were each based on a single Likert scale question and not validated survey instruments, which may have yielded different results, they cautioned.

Source Reference: , 2019; DOI:10.1001/jamasurg.2019.0029

Study Highlights: Explanation of Findings

Higher rates of 30-day complications and resource utilization were noted among blacks versus whites from the Michigan Bariatric Surgery Collaborative who underwent bariatric surgeries. They also experienced lower weight loss at 1 year versus whites. Comorbidity remission was similar between the races, except for lower hypertension remission, higher sleep apnea, and gastroesophageal reflux disease remission among black patients.

"Although we found a higher rate of overall complications for black patients, the rate of serious complications and mortality were not significantly different," the authors pointed out. Finks and colleagues also suggested that the surgeon and site of care were two of the possible explanations for more severe adverse events.

By contrast, data from the Longitudinal Assessment of Bariatric Surgery () and an analysis of following bariatric surgery showed that race was not a significant risk factor for adverse outcomes or serious complications, respectively. Unlike other reports, Finks and colleagues stated that the current study was a large, population-based, robust clinical registry and also looked at vertical sleeve gastrectomy. "Fewer studies have examined racial differences in weight loss after vertical sleeve gastrectomy and results have been mixed," they stated.

However, findings from other literature reports were similar to the results of the current study. Analysis of showed that the odds of readmission were 34% higher for black patients than white patients after Roux-en-Y gastric bypass. A of New York State hospital discharge data showed that black patients were at significantly greater risk for a potentially preventable readmission after bariatric surgery than white patients.

The authors speculated about reasons other than surgeon or site that could explain their findings, such as biological determinants and differences in total and resting energy expenditures among the races. Socio-environmental factors might also have played a role, as predominantly black areas (regardless of income) were less likely than predominantly white, higher-income communities to have access to foods meeting recommended dietary standards.

"Access to transportation and availability of recreation centers also appear to contribute to the obesogenicity of different living environments," Finks and colleagues wrote.

In an , Brian Hodgens, MD, and Kenric M. Murayama, MD, both of the University of Hawaii at Manoa in Honolulu, pointed out that patient-reported satisfaction and quality-of-life differences were relatively small between the groups, which brings up another topic for discussion: "cultural attitudes toward medicine and weight loss," they noted.

"Interestingly, in this study, the authors report that 'black patients were more likely than white patients to report good or very good quality of life at baseline ... but were less likely to do so at 1 year after surgery.' This difference in perceptions of obesity by black patients may lead to pursuing treatment later and possibly not as enthusiastically," Hodgens and Murayama explained.

The commenters said that until future research on this topic is conducted, bariatric surgeons can use the study to help manage individual patient expectations after surgery.

Ultimately, it is worth noting that obesity . In addition to obesity-related changes in fat utilization and breakdown, obesity might also affect regulators of appetite and hunger in a manner that can cause an increase in the amount of food eaten at any given meal and the desire to eat more often, according to the American Society for Metabolic and Bariatric Surgery. The complex interplay involving surgical technique, altered metabolism, genetics, and race that provides the biological framework for how weight is "kept off" or regained is the subject of ongoing investigations.

A summarized suggestions that might help to enhance weight loss interventions for black Americans, which may also apply to patients undergoing bariatric surgeries. The reviewers suggested developing and refining e-health approaches and faith-based or other culturally and contextually relevant approaches, as indicated.