Racial Disparities in Obesity Treatment

Racial and weight discrimination associations with pain intensity and pain interference in an ethnically diverse sample of adults with obesity: a baseline analysis of the clustered randomized-controlled clinical trial the goals for eating and moving (GEM) study

BACKGROUND

Everyday experiences with racial (RD) and weight discrimination (WD) are risk factors for chronic pain in ethnically diverse adults with obesity. However, the individual or combined effects of RD and WD on pain in adults with obesity is not well understood. There are gender differences and sexual dimorphisms in nociception and pain, but the effect of gender on relationships between RD, WD, and pain outcomes in ethnically diverse adults with obesity is unclear. Thus, the purposes of this study were to: 1) examine whether RD and WD are associated with pain intensity and interference, and 2) explore gender as a moderator of the associations between RD, WD, and pain.

METHODS

This is a baseline data analysis from a randomized, controlled clinical trial of a lifestyle weight-management intervention. Eligible participants were English or Spanish-speaking (ages 18-69 years) and had either a body mass index of ≥30 kg/m2 or ≥ 25 kg/m2 with weight-related comorbidity. RD and WD were measured using questions derived from the Experiences of Discrimination questionnaire (EOD). Pain interference and intensity were measured using the PROMIS 29 adult profile V2.1. Linear regression models were performed to determine the associations between WD, RD, gender, and pain outcomes.

RESULTS

Participants (n = 483) reported mild pain interference (T-score: 52.65 ± 10.29) and moderate pain intensity (4.23 ± 3.15). RD was more strongly associated with pain interference in women (b = .47, SE = .08, p < 001), compared to men (b = .14, SE = .07, p = .06). Also, there were no significant interaction effects between RD and gender on pain intensity, or between WD and gender on pain interference or pain intensity.

CONCLUSIONS

Pain is highly prevalent in adults with obesity, and is impacted by the frequencies of experiences with RD and WD. Further, discrimination against adults with obesity and chronic pain could exacerbate existing racial disparities in pain and weight management. Asking ethnically diverse adults with obesity about their pain and their experiences of RD and WD could help clinicians make culturally informed assessment and intervention decisions that address barriers to pain relief and weight loss.

TRIAL REGISTRATION

NCT03006328.

Rural/urban weight-loss outcomes following bariatric surgery

Obesity disproportionately affects rural populations; however, there is limited research examining disparities in bariatric surgery outcomes between patients from rural versus urban areas. This study aimed to compare the demographic characteristics of patients undergoing bariatric surgery from rural versus urban bariatric areas and to explore differences in weight-loss outcomes between these groups. A retrospective chart review identified a sample of 170 patients (52 rural, 118 urban) who underwent Roux-en-Y gastric bypass or vertical sleeve gastrectomy procedures over a 1-year period. Data collected included age, race, gender, insurance status, surgery type, height, and pre- and postoperative weights at 3 and 6 months. Significant differences in race, ethnicity, and surgery type were observed between rural/urban patients (ps < 0.05). Patients from rural areas demonstrated significantly greater percent total weight losses at 3 months (p = 0.018; however, there were no significant differences between groups at 6 months (p > 0.05). The results suggest that patients from rural counties experience postoperative weight-loss outcomes comparable to those of their urban counterparts.

Moving Toward Health Policy that Respects Both Science and People Living with Obesity

Through four decades of rising obesity, health policy has been mostly ineffective. Prevention policies failed to reverse rising trends in prevalence, partly because they are often based on biased mental models about what should work to prevent obesity, rather than empiric evidence for what does work. Bias toward people living with obesity harms health, while contributing to poor access to effective care that might serve to improve it. Better public policy will come from an increased application of objective obesity science, research to fill knowledge gaps, and respect for the human dignity of people who live with obesity.

Restriction of range effects in post-metabolic and bariatric surgery outcomes research: considerations for clinical decision making

BACKGROUND

Preoperative psychopathology does not consistently predict postoperative outcomes in patients who undergo metabolic and bariatric surgery (MBS). Individuals with elevated pre-MBS psychopathology may be less likely to undergo surgery, which may create a floor effect given the limited range of scores on measures of psychopathology included in postoperative analyses, thereby decreasing the power to detect clinically significant differences between groups.

OBJECTIVES

Our objective was to compare rates of clinically significant pre-MBS psychopathology across domains of functioning in patients who did and did not undergo MBS: surgical completers (SCs, n = 286) and nonsurgical completers (NSCs, n = 125).

SETTING

Academic medical center, United States.

METHODS

Participants (n = 411) were a racially diverse sample of MBS candidates who completed a preoperative psychosocial evaluation including measures of disordered eating, alcohol and tobacco use, pain catastrophizing, anxiety, and depressive symptomatology.

RESULTS

Compared with SCs, NSCs had larger scale score variance on measures of psychopathology and were more likely to be Black; to report clinically significant scores on measures of binge eating, depression, anxiety, and pain catastrophizing; and to use tobacco.

CONCLUSION

Results support the presence of a restriction-of-range effect but do not demonstrate a floor effect. These data suggest that current outcome data for MBS patients may not generalize to those who report clinically significant psychopathology at the pre-MBS psychosocial evaluation and may warrant caution when using the current literature to inform clinical decision making for this group. Findings also suggest a need for interventions that will better engage Black patients.

Patient Access, Utilization, and Perceptions of Neighborhood and Built Environment Resources

Purpose

There is a critical need to explore bariatric patients’ perceptions of existing neighborhood and built environment resources and supports to assist with postoperative behavior change and weight loss maintenance. The objective of this study was to survey postoperative patients to determine neighborhood food retail, fitness facility, and options for outdoor activity access, utilization, satisfaction, and perceptions of resources.

Materials and Methods

A convenience sample of postoperative patients from a single academic surgical center in the USA (N = 44) completed an online survey about access, utilization, satisfaction, and safety for food retail, fitness facility, and outdoor activity options in their neighborhoods. Analysis included descriptives (frequency, percent, Chi-square), and independent samples t tests and ANOVA determined differences based on race, insurance status, geographic location, and receipt of governmental assistance programs. Open-ended questions were analyzed using summative content analysis.

Results

Patients reported the highest access to lower-cost national food retailers and fitness facilities. The most prevalent challenge in finding food products to meet patients’ goals was financial (39%). Patients’ top suggestions for fitness facilities included training staff/facilities (59%) and trainers (35%) in postoperative patient care and exercise. The highest access for outdoor activity options was for walking/running trails, city/metro parks, and sidewalks. Significant differences in access, utilization, and safety were found based on geographic location, receipt of at least one assistant program, and race.

Conclusion

The development of targeted resources may benefit patients in non-suburban areas and who receive governmental assistant programs to increase safety of outdoor options and access to lower-cost food retailers and to increase utilization of lower-cost fitness facilities.

Graphical abstract

Attitudes, Perceptions, and Practices in Managing Obesity Among Endocrinologists

OBJECTIVE

Obesity is globally recognized as a critically important disease by professional medical organizations in addition to the World Health Organization and American Medical Association, but the health care systems, medical teams, and the public have been slow to embrace this concept.

METHODS

American Association of Clinical Endocrinology (AACE) staff drafted the survey, and two endocrinologists independently reviewed the survey questions and modified the survey instrument. The survey included inquiries related to practice and patient demographics, awareness of obesity, treatment of obesity, barriers to improving obesity outcomes, digital health, cognitive behavioral therapy, lifestyle medicine, anti-obesity medications, weight stigma, and social determinants of health. The survey was emailed to 493 endocrinologists, with 305 completing the study (62%).

RESULTS

Ninety-eight percent of the responders agree that obesity is a disease, while 2% neither agree nor disagree. 53% of respondents are familiar with the term "adiposity-based chronic disease." 13% of the respondents are certified by the American Board of Obesity Medicine (ABOM). 57% of the respondents use published obesity guidelines as a resource for treating patients with obesity. Most endocrinologists recommend dietary and lifestyle changes, but fewer prescribe anti-obesity medication (AOM) or recommend bariatric surgery. ABOM-certified endocrinologists are more likely to use a multidisciplinary approach.

CONCLUSION

Self-reported knowledge and practices in the management of obesity highlight the importance of a multimodal approach to obesity and foster collaboration among healthcare professionals. It is necessary to raise awareness about obesity among clinicians, identify knowledge gaps and create educational tools to address those gaps.

Coverage of obesity and obesity disparities on American Board of Medical Specialties (ABMS) examinations

Obesity is a widespread disease which adversely impacts all organ systems and disproportionately affects African Americans and other minority groups. Physicians across medical specialties must possess current knowledge of obesity as an important, distinct disease with biological and social causes. Coverage of obesity on board certification examinations, which influence standards in medical knowledge and practice in each specialty, has not previously been examined. The member boards of the American Board of Medical Specialties offer a content outline or "blueprint" detailing material tested. We parsed the 24 available general certification exam blueprints for mentions of obesity and related keywords. We categorized blueprints into three tiers: mention of obesity (Tier 1), mention of related terminology but not obesity (Tier 2), and no mention of obesity or related terminology (Tier 3). We analyzed mentions of obesity and related terms by blueprint word count and procedural versus non-procedural specialties. Six (25.0%) of 24 board exam blueprints mentioned obesity (Tier 1), fifteen (62.5%) mentioned related terminology only (Tier 2), and three (12.5%) mentioned neither obesity nor related terminology (Tier 3). There was no significant difference in obesity-related mentions between procedural and non-procedural specialties (X2, p = .50). None of the blueprints included racial/ethnic disparities related to obesity. Word count was not significantly correlated with mentions of obesity in linear regression (p = .42). The absence of any mention of obesity on most content outlines and of racial/ethnic disparities on all content outlines indicates need for increased coverage of the diagnosis, prevention, and treatment of obesity across all board examinations.

Denominational Differences in Obesity Among Black Christian Adults: Why Gender and Life Stage Matter

Religiosity is a potential social determinant of obesity risk among black Americans, a group that tends to be highly religious and disproportionately suffers from this disease. Although religious engagement differs within this group, researchers often classify black Protestants into broad categories, making it challenging to determine which subgroups experience the worst outcomes. Using data from the National Survey of American Life, this study investigated whether black adults from various Christian denominations had comparable odds of having obesity and if these findings were consistent across life stage (i.e., young, middle, and late adulthood). Results suggest that for middle-aged Pentecostal women, and men and women who attend church most frequently, the odds of having obesity were comparably higher than their respective counterparts. These findings indicate that, even when denominational consolidation is appropriate in other religious research contexts, researchers should consider diaggregating black Christians by denomination when examining the relationship between religion and health.

The role of structure in dietary approaches for the treatment of pediatric overweight and obesity: A critical review

A multicomponent approach for the treatment of pediatric overweight/obesity, which includes behavioral strategies to alter diet and physical activity/sedentary behavior, has graded recommendations for its use. Dietary interventions to be used within this approach do not. In adults, research indicates that strongly graded dietary interventions providing greater structure (or more control over the types/amount of food consumed) produce better weight outcomes. For this critical review, dietary interventions recommended by the Expert Committee for the treatment of pediatric overweight/obesity were categorized according to their potential degree of dietary structure, and their impact on weight outcomes was described. Four levels of dietary structure were reviewed, operationalized as alterations to the following: food groups, such as fruits and vegetables (low structure); daily eating occasions, such as meals (moderate structure); large nutrients, such as energy (high structure); and energy plus additional dietary alterations (very high structure). In total, 24 interventions (four low, three moderate, five high, and 12 very high structure structure) were identified and reviewed. Reductions in standardized body mass index increased with increasing structure, and interventions ≥6 months had better outcomes than interventions <6 months. Future research should empirically test dietary intervention structure to determine its impact on weight status during pediatric overweight/obesity treatment.

Implementation of a Scalable Family-Based Behavioral Treatment for Childhood Obesity Delivered through Primary Care Clinics: Description of the Missouri Childhood Obesity Research Demonstration Study Protocol

Background: Significant gaps exist in access to evidence-based pediatric weight management interventions, especially for low-income families who are disproportionately affected by obesity. As a part of the Centers for Disease Control and Prevention's Childhood Obesity Research Demonstration project (CORD 3.0), the Missouri team (MO-CORD) aims to increase access to and dissemination of an efficacious pediatric obesity treatment, specifically family-based behavioral treatment (FBT), for low-income families. Methods/Design: The implementation pilot study is a multisite matched-comparison group pilot of packaged FBT in pediatric clinics for low-income children with obesity, of ages 5 to 12 years old. The study is implemented in two Missouri pediatric primary care clinical sites, Freeman Health System Pediatric Clinics (rural Joplin) and Children's Mercy Hospital Pediatric Clinics (urban Kansas City). The design focuses on pragmatism through utilization of PRECIS (Pragmatic Explanatory Continuum Indicator Summary) domains, such as open eligibility criteria, limited follow-up intensity, reliance on medical records for creating a usual care comparison group data, and unobtrusive measurement of participant and provider adherence. The evaluation focuses on effectiveness as well as implementation outcomes and barriers to inform implementation scale up. Conclusions: Findings from this study will advance both science and practice by providing novel and immediately useful information to families, health care providers, health care organizations, payers, and other state Medicaid plans by developing and optimizing evidence-based pediatric weight management treatment for implementation and dissemination in health systems to address health disparities among low-income populations most affected by overweight and obesity.

Racial Disparities in Obesity Treatment Among Children and Adolescents

PURPOSE OF REVIEW

With the growing obesity epidemic among children and adolescents, the evaluation of disease origin to slow disease progression is necessary. Racial disparities which are evident amid prevalence and treatment must be studied to counteract disease propagation.

RECENT FINDINGS

Disparities are pronounced among Black and Hispanic pediatric patients prior to conception and birth due to genetic composition and fetal environment. Postnatal environment and psychosocial influences can further increase a child/adolescent's propensity to increased weight. Current treatment options including nutrition, physical activity, behavior modification, pharmacotherapy, and surgery are underutilized in communities of color due to limited access to care and cost. Data is limited to demonstrate disparities among treatment of obesity in children and adolescents. The reviewed studies show the role of race on disease treatment. Increased research efforts, especially in pharmacotherapy and metabolic and bariatric surgery (MBS), will help combat obesity in pediatric communities of color.

Factors associated with early gestational weight gain among women with pre-pregnancy overweight or obesity

The present study aimed to document the prevalence of and identify factors associated with excessive gestational weight gain (GWG) in early pregnancy among women with pre-pregnancy overweight or obesity. Women with pre-pregnancy overweight or obesity (n = 247) were recruited between 12 and 20 weeks of gestation and completed questionnaires and were weighed to estimate early GWG. Nearly one-third of women met (17%, n = 42) or exceeded (13%, n = 33) guidelines for total GWG in early pregnancy. Univariate analyses showed race, income, and pre-pregnancy weight status to be significantly related to GWG category in early pregnancy (p < .009). Only race and pre-pregnancy weight status remained significant in a multivariate model, with Black women and women with pre-pregnancy obesity having higher odds of having met or exceeded guidelines for total GWG in early pregnancy compared with White women and women with pre-pregnancy overweight (p < .04). These findings highlight the need for early intervention to reduce weight-related complications among pregnant women.Impact statementWhat is already known on this subject? Women with pre-pregnancy overweight or obesity who gain excessive gestational weight early in pregnancy are at unique risk for pregnancy complications and adverse birth outcomes.What do the results of this study add? The present study adds to a growing body of literature documenting that a notable amount of women are gaining excessive gestational weight early in pregnancy. The present study further documents that Black women and women with pre-pregnancy obesity are at particular risk of gaining excessive gestational weight early in pregnancy.What are the implications of these findings for clinical practice and/or further research? Additional work examining modifiable risk factors, particularly among Black women and women with pre-pregnancy obesity, that contribute to excessive gestational weight gain (GWG) in the first half of pregnancy is warranted and will be necessary to inform interventions aimed at promoting weight loss during the preconception and interconception periods or encouraging appropriate GWG across the entire course of pregnancy.

Is obesity a manifestation of systemic racism? A ten-point strategy for study and intervention

In the recent past, there has been rising attention to systemic racism. The ensuing discussions have largely focused on COVID-19 and policing. Despite long-standing disparities in obesity across racial and ethnic groups and obesity's important role in COVID-19 disparities, there has been minimal attention to whether obesity itself could be a manifestation of systemic racism. Nor has there been serious policy attention dedicated to alleviating obesity and its disproportionate burden on BIPOC (Black, Indigenous, and People of Color). We discuss whether obesity's disproportionate harms to BIPOC may be attributed to systemic racism, and we provide a ten-point strategy for studying and solving the core public health issues at the intersection of obesity and systemic racism.

Running the Obstacle Course: Improving the Utilization of Bariatric Surgery in Adolescent Obesity

The obesity epidemic in the adolescent population continues to worsen despite increased awareness. Although there is an improved understanding of the role of bariatric surgery in the treatment of obesity in adolescents, a number of barriers still prevent its widespread utilization. The lack of formal obesity-focused education in the training curricula of primary care providers (PCPs), coupled with variable distribution of comprehensive resources, creates an inhospitable environment for effective anti-obesity treatment in adolescents. In addition, racial disparities and variability in insurance coverage contribute to the complexity of this problem. The coronavirus disease 2019 (COVID-19) pandemic has exacerbated the rate of childhood obesity and emphasized the need for bariatric surgery as an adjunctive treatment. This article highlights 3 barriers to bariatric surgery: (1) hesitation to refer for surgery; (2) limitation in available resources; and (3) racial disparities in anti-obesity treatment. Potential systemic solutions to such obstacles are examined.

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

Efficacy of Clinic-Based Telehealth vs. Face-to-Face Interventions for Obesity Treatment in Children and Adolescents in the United States and Canada: A Systematic Review

Background: Childhood obesity is an ever-growing public health concern in the United States and globally. By 2030, it is estimated that 70% of the world's population of children and adolescents will be obese. Therefore, efforts to reduce childhood obesity are of utmost importance, particularly with the current coronavirus disease 2019 pandemic, as rates are expected to soar due to social distancing measures and restrictions. This systematic review aims to examine the literature regarding the effectiveness of clinic-based telehealth vs. face-to-face modalities to reduce obesity among school-aged children. Methods: An electronic database search of articles published in English over the last 10 years was undertaken in PubMed, Medline, and CINAHL. Key terms used to identify studies included school-aged children and adolescents with overweight and obesity in clinic-based weight management interventions conducted face-to-face or via telehealth, and having efficacy determined through changes in measured child BMI as primary outcomes and dietary and physical activity changes, as well as assessing feasibility and satisfaction with telehealth, as secondary outcomes. Results: Out of 1093 articles identified, 10 met the inclusion criteria. While both telehealth and face-to-face weight management interventions are effective in reducing obesity in children and adolescents, the evidence is lacking in which is more effective. Of the 10 studies, 5 showed outcome improvements when both telehealth and face-to-face interventions were combined as adjunct therapies. Conclusions: Findings support using telehealth in conjunction with face-to-face visits for obesity treatment among children and adolescents. However, more research involving telehealth weight management interventions for young children is recommended.

Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial

Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.

Reducing HPV Associated Cancers and Disparities: Engaging African American Men to Develop a Culturally-Appropriate Program that Addresses their Needs

Background

The Healthy Men, Health Communities program aims to improve preventive behaviors among African American men to reduce HPV-related cancer disparities.

Purpose

We describe the development of an educational intervention using cultural-targeting strategies (i.e., linguistics, peripherals, evidence, socio-culture, and constituent-involving).

Methods

After building capacity of community-based organization (CBO) leaders as research team members, we conducted 3 focus groups, 30 surveys, and a community review and program evaluation with African American men.

Results

Focus group themes were: 1) The Known and Unknown of Cancer, HPV, and the vaccine; (2) Personal experiences with cancer were commonplace; (3) Barriers to Engaging HPV Cancer Preventive Behaviors; (4) Multi-Modal Strategies are needed to improve preventive behaviors; and (5) Actual versus Preferred Sources of Information. Survey data indicated men desired information on penile (52%) and oral cancers (48%). The preferred education format was a summit with speakers on various topics (96%). Post-summit evaluation indicated majority of males intended to get screened (73%), eat healthier (77%), and exercise more (64%). About 40% reported getting themselves, children, or grandchildren the HPV vaccine.

Discussion

Our program demonstrated acceptability, feasibility, and preliminary efficacy. This work warrants further study as a potential program to improve HPV preventive behaviors among African American men.

Using measured resting metabolic rate to derive calorie prescriptions in a behavioral weight loss program

OBJECTIVE

Within behavioral weight loss (BWL) programs, using measured resting metabolic rate (RMR) is a more accurate-yet costlier-alternative to the standard method of assigning calorie prescriptions using baseline weight. This investigation aimed to assess differences between calorie goals prescribed using each method including demographic predictors and associations with weight loss.

METHODS

This is an ancillary study to a trial comparing approaches to motivational enhancement in a 6-months BWL program designed for emerging adults age 18-25 (N = 308). RMR was measured at baseline and used to derive calorie prescriptions; standard calorie goals were retrospectively assigned for the purpose of these analyses.

RESULTS

Standard calorie prescriptions were significantly higher than those derived from RMR. Sex and race were significant predictors of calorie prescription discrepancies: using the standard method, women and Black participants were assigned higher calorie goals than their RMR would indicate. Calorie goal discrepancy did not predict 6-months weight change.

CONCLUSIONS

Differences in calorie prescriptions between approaches were significant; however, it remains to be determined whether measuring RMR is worth the cost, time, and participant burden. It may be the case that this consideration has greater impact for certain subgroups-namely, women and Black participants.

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.

Aging and COVID-19 in Minority Populations: a Perfect Storm

PURPOSE OF REVIEW

COVID-19 is a major concern for the health and wellbeing of individuals worldwide. As COVID-19 cases and deaths continue to increase in the USA, aging Black and Hispanic populations have emerged as especially at-risk for increased exposure to COVID-19 and susceptibility to severe health outcomes. The current review discusses the weathering hypothesis and the influence of social inequality on the identified health disparities.

RECENT FINDINGS

Aging minoritized populations have endured structural and social inequality over the lifecourse. Consequently, these populations experience weathering, a process that results in physiological dysregulation due to stress associated with persistent disadvantage. Through weathering and continued inequity, aging minoritized populations have an increased risk of exposure and poor health outcomes from COVID-19.

SUMMARY

Current literature and available data suggests that aging minoritized persons experience high rates of COVID-19 morbidity and mortality. The current review hypothesizes and supports that observed disparities are the result of inequalities that especially affect Black and Hispanic populations over the lifecourse. Future efforts to address these disparities should emphasize research that supports governments in identifying at-risk groups, providing accessible COVID-19-related information to those groups, and implementing policy that addresses the structural and social inequities that perpetuate current COVID-19 disparities.

Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.

Disparities in Cardiovascular Disease Outcomes Among Pregnant and Post-Partum Women

Background The incidence of cardiovascular disease among pregnant women is rising in the United States. Data on racial disparities for the major cardiovascular events during pregnancy are limited. Methods and Results Pregnant and post-partum women hospitalized from January 2007 to December 2017 were identified from the Nationwide Inpatient Sample. The outcomes of interest included: in-hospital mortality, myocardial infarction, stroke, pulmonary embolism, and peripartum cardiomyopathy. Multivariate regression analysis was used to assess the independent association between race and in-hospital outcomes. Among 46 700 637 pregnancy-related hospitalizations, 21 663 575 (46.4%) were White, 6 302 089 (13.5%) were Black, and 8 914 065 (19.1%) were Hispanic. The trends of mortality and stroke declined significantly in Black women, but however, were mostly unchanged among White women. The incidence of mortality and cardiovascular morbidity was highest among Black women followed by White women, then Hispanic women. The majority of Blacks (62.3%) were insured by Medicaid while the majority of White patients had private insurance (61.9%). Most of Black women were below-median income (71.2%) while over half of the White patients were above the median income (52.7%). Compared with White women, Black women had the highest mortality with adjusted odds ratio (aOR) of 1.45, 95% CI (1.21-1.73); myocardial infarction with aOR of 1.23, 95% CI (1.06-1.42); stroke with aOR of 1.57, 95% CI (1.41-1.74); pulmonary embolism with aOR of 1.42, 95% CI (1.30-1.56); and peripartum cardiomyopathy with aOR of 1.71, 95 % CI (1.66-1.76). Conclusions Significant racial disparities exist in major cardiovascular events among pregnant and post-partum women. Further efforts are needed to minimize these differences.

An Exploratory Study of the Acceptability and Feasibility of Yoga Among Women in Substance Use Disorder Recovery

Objectives: This qualitative study explored the acceptability and feasibility of yoga among women in substance use disorder (SUD) recovery. Design: Seventeen women in SUD recovery for 2 weeks or longer were recruited from nine sites in the mid-South, including a Medication-Assisted Treatment clinic in a hospital setting, prison re-entry housing, community-based peer support organizations (e.g., Alcoholics Anonymous [AA], Narcotics Anonymous [NA]), a residential SUD treatment facility, a yoga teachers' online group, and through referrals. The median age of participants was 41.5, with ages ranging from 25 to 65. We used an interpretive description approach to explore both the perceptions of women without yoga experience and the experiences of women with yoga experience to collect formative data for intervention development and implementation. The interviews were recorded and transcribed verbatim. A hybrid analysis (i.e., inductive and deductive coding) was applied to the data. Results: Women's narratives included a high prevalence of trauma exposure. Overall, women in this sample were interested in either beginning or continuing yoga. Barriers to participation included perceived lack of self-efficacy of yoga, weight, and physical injuries. Additional environmental barriers included balancing care of self with caring for others, including partners, children, and NA/AA sponsees; as well as prioritizing finances, housing, employment, and transportation. Conclusion: High prevalence of trauma exposure among women in SUD recovery necessitates careful consideration of co-occurring psychiatric disorders such as post-traumatic stress disorder, anxiety and depression and the necessary professional psychological support, as well as serious physical injuries that require modification in yoga āsana classes. As transportation and balancing care needs were salient in these data, rural SUD populations could be served with telehealth interventions that provide SUD recovery support with integrative health practices such as adjunctive yoga interventions.

Influence of BDNF Genetic Polymorphisms in the Pathophysiology of Aging-related Diseases

For the first time in history, most of the population has a life expectancy equal or greater than 60 years. By the year 2050, it is expected that the world population in that age range will reach 2000 million, an increase of 900 million with respect to 2015, which poses new challenges for health systems. In this way, it is relevant to analyze the most common diseases associated with the aging process, namely Alzheimer´s disease, Parkinson Disease and Type II Diabetes, some of which may have a common genetic component that can be detected before manifesting, in order to delay their progress. Genetic inheritance and epigenetics are factors that could be linked in the development of these pathologies. Some researchers indicate that the BDNF gene is a common factor of these diseases, and apparently some of its polymorphisms favor the progression of them. In this regard, alterations in the level of BDNF expression and secretion, due to polymorphisms, could be linked to the development and/or progression of neurodegenerative and metabolic disorders. In this review we will deepen on the different polymorphisms in the BDNF gene and their possible association with age-related pathologies, to open the possibilities of potential therapeutic targets.

Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Background: Effective provision of bariatric surgery for patients with obesity may be impeded by concerns of payers regarding costs or perceptions of patients who drop out of surgical programs after referral. Estimates of the cost and comorbidity impact of these inefficiencies in gastric bypass surgery in Canada are lacking but would aid in informing healthcare investment and resource allocation.

Objectives: To estimate total and relative public payer costs for surgery and comorbidities (diabetes, hypertension, and dyslipidemia) in a bariatric surgery population.

Methods: A decision analytic model for a 100-patient cohort in Canada (91% female, mean body mass index 49.2 kg/m², 50% diabetes, 66% hypertension, 59% dyslipidemia). Costs include surgery, surgical complications, and comorbidities over the 10-year post-referral period. Results are calculated as medians and 95% credibility intervals (CrIs) for a pathway with surgery at 1 year (“improved”) compared with surgery at 3.5 years (“standard”). Sensitivity analyses were performed to test independent contributions to results of shorter wait time, better post-surgical weight loss, and randomly sampled cohort demographics.

Results: Compared to standard care, the improved path was associated with reduction in patient-years of treatment for each of the three comorbidities, corresponding to a reduction of $1.1 (0.68–1.6) million, or 34% (26-41%) of total costs. Comorbidity treatment costs were 9.0- and 4.7-fold greater than surgical costs for the standard and improved pathways, respectively. Relative to non-surgical bariatric care, earlier surgery was associated with earlier return on surgical investment and 2-fold reduction in risk of prevalence of each comorbidity compared to delayed surgery.

Conclusions: Comorbidity costs represent a greater burden to payers than the costs of gastric bypass surgery. Investments may be worthwhile to reduce wait times and dropout rates and improve post-surgical weight loss outcomes to save overall costs and reduce patient comorbidity prevalence.

Caloric restriction recovers impaired β-cell-β-cell gap junction coupling, calcium oscillation coordination, and insulin secretion in prediabetic mice

Caloric restriction can decrease the incidence of metabolic diseases, such as obesity and Type 2 diabetes mellitus. The mechanisms underlying the benefits of caloric restriction involved in insulin secretion and glucose homeostasis are not fully understood. Intercellular communication within the islets of Langerhans, mediated by Connexin36 (Cx36) gap junctions, regulates insulin secretion dynamics and glucose homeostasis. The goal of this study was to determine whether caloric restriction can protect against decreases in Cx36 gap junction coupling and altered islet function induced in models of obesity and prediabetes. C57BL6 mice were fed with a high-fat diet (HFD), showing indications of prediabetes after 2 mo, including weight gain, insulin resistance, and elevated fasting glucose and insulin levels. Subsequently, mice were submitted to 1 mo of 40% caloric restriction (2 g/day of HFD). Mice under 40% caloric restriction showed reversal in weight gain and recovered insulin sensitivity, fasting glucose, and insulin levels. In islets of mice fed the HFD, caloric restriction protected against obesity-induced decreases in gap junction coupling and preserved glucose-stimulated calcium signaling, including Ca2+ oscillation coordination and oscillation amplitude. Caloric restriction also promoted a slight increase in glucose metabolism, as measured by increased NAD(P)H autofluorescence, as well as recovering glucose-stimulated insulin secretion. We conclude that declines in Cx36 gap junction coupling that occur in obesity can be completely recovered by caloric restriction and obesity reversal, improving Ca2+ dynamics and insulin secretion regulation. This suggests a critical role for caloric restriction in the context of obesity to prevent islet dysfunction.

Race, racism and disparities in obesity rates in the US

Click here to view the Letter to the Editor by Gower et al.

Use of sleeve gastrectomy in adolescents and young adults with severe obesity

PURPOSE OF REVIEW

The prevalence of pediatric obesity and its associated complications is increasing around the world. Treatment of obesity is challenging and metabolic and bariatric surgery (MBS) is currently the most effective treatment for this condition. At this time, vertical sleeve gastrectomy (VSG) is the most commonly performed bariatric procedure in adolescents. However, knowledge regarding the efficacy, safety, and durability of VSG in adolescents is still evolving. This review summarizes the most recent updates in the field of MBS particularly VSG in adolescents.

RECENT FINDINGS

MBS is recommended to treat moderate to severe obesity, especially when complicated by comorbidities. The use of VSG for weight loss is increasing among adolescents and produces similar weight loss at five years in both adolescents and adults. The physiologic mechanisms causing weight loss after VSG are multifactorial and still being investigated. The complication rate after VSG ranges between 0 and 17.5%.

SUMMARY

VSG appears to be a well-tolerated and effective procedure in adolescents. However, it continues to be underutilized despite the increasing prevalence of moderate to severe obesity in adolescents. It is thus important to educate providers regarding its benefits and safety profile.

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.

The Contribution of Race to Breast Tumor Microenvironment Composition and Disease Progression

Breast cancer is the second most commonly diagnosed cancer in American women following skin cancer. Despite overall decrease in breast cancer mortality due to advances in treatment and earlier screening, black patients continue to have 40% higher risk of breast cancer related death compared to white patients. This disparity in outcome persists even when controlled for access to care and stage at presentation and has been attributed to differences in tumor subtypes or gene expression profiles. There is emerging evidence that the tumor microenvironment (TME) may contribute to the racial disparities in outcome as well. Here, we provide a comprehensive review of current literature available regarding race-dependent differences in the TME. Notably, black patients tend to have a higher density of pro-tumorigenic immune cells (e.g., M2 macrophages, regulatory T cells) and microvasculature. Although immune cells are classically thought to be anti-tumorigenic, increase in M2 macrophages and angiogenesis may lead to a paradoxical increase in metastasis by forming doorways of tumor cell intravasation called tumor microenvironment of metastasis (TMEM). Furthermore, black patients also have higher serum levels of inflammatory cytokines, which provide a positive feedback loop in creating a pro-metastatic TME. Lastly, we propose that the higher density of immune cells and angiogenesis observed in the TME of black patients may be a result of evolutionary selection for a more robust immune response in patients of African geographic ancestry. Better understanding of race-dependent differences in the TME will aid in overcoming the racial disparity in breast cancer mortality.

A Structural Competency Curriculum for Primary Care Providers to Address the Opioid Use Disorder, HIV, and Hepatitis C Syndemic

The interrelated epidemics of opioid use disorder (OUD) and HIV and hepatitis C virus (HCV) infection have been identified as one of the most pressing syndemics facing the United States today. Research studies and interventions have begun to address the structural factors that promote the inter-relations between these conditions and a number of training programs to improve structural awareness have targeted physician trainees (e.g., residents and medical students). However, a significant limitation in these programs is the failure to include practicing primary care providers (PCPs). Over the past 5 years, there have been increasing calls for PCPs to develop structural competency as a way to provide a more integrated and patient-centered approach to prevention and care in the syndemic. This paper applies Metzel and Hansen's (1) framework for improved structural competency to describe an educational curriculum that can be delivered to practicing PCPs. Skill 1 involves reviewing the historical precedents (particularly stigma) that created the siloed systems of care for OUD, HIV, and HCV and examines how recent biomedical advances allow for greater care integration. To help clinicians develop a more multidisciplinary understanding of structure (Skill 2), trainees will discuss ways to assess structural vulnerability. Next, providers will review case studies to better understand how structural foundations are usually seen as cultural representations (Skill 3). Developing structural interventions (Skill 4) involves identifying ways to create a more integrated system of care that can overcome clinical inertia. Finally, the training will emphasize cultural humility (Skill 5) through empathetic and non-judgmental patient interactions. Demonstrating understanding of the structural barriers that patients face is expected to enhance patient trust and increase retention in care. The immediate objective is to pilot test the feasibility of the curriculum in a small sample of primary care sites and develop metrics for future evaluation. While the short-term goal is to test the model among practicing PCPs, the long-term goal is to implement the training practice-wide to ensure structural competence throughout the clinical setting.

Identifying and Addressing Individuals Resistant to Behavioral Lifestyle Treatment

The prevention and treatment of lifestyle disease involves overlapping factors. Those at the highest risk for the development of lifestyle disease are also at the highest risk for poor treatment outcomes. Although behavioral treatment of lifestyle disease has demonstrated efficacy on average, considerable individual variation exists in treatment response. In clinical settings, individuals unresponsive to treatment are typically provided escalated care. Community-based care is designed to reach high-risk populations unlikely to seek medical care. However, in community settings escalated treatment options are not usually available for individuals unresponsive to treatment. Addressing this gap is imperative to improve health outcomes of high-risk populations and to identify individuals who may be resistant to behavioral lifestyle treatment.

Racial Comparisons of Postoperative Weight Loss and Eating-Disorder Psychopathology Among Patients Following Sleeve Gastrectomy Surgery

OBJECTIVE

This study aimed to examine racial differences in postoperative eating-disorder psychopathology, psychosocial functioning, and weight loss among adults with loss-of-control (LOC) eating following sleeve gastrectomy.

METHODS

Participants were 123 patients (n = 74 non-Hispanic White and n = 49 non-Hispanic Black) who underwent sleeve gastrectomy surgery within the previous 4 to 9 months and reported regular LOC eating during the previous month. The Eating Disorder Examination Bariatric Surgery Version assessed LOC eating, eating-disorder psychopathology, and meal patterns. Participants completed self-report measures, including the Beck Depression Inventory-II and Medical Outcomes Study Short-Form Health Survey.

RESULTS

Presurgical BMI did not differ by race, but Black patients had significantly less percent total weight loss and percent excess weight loss than White patients. Black and White patients did not differ significantly in LOC eating frequency, onset time of postoperative LOC eating, eating-disorder psychopathology, depressive symptoms, or physical or mental health-related quality of life. White patients were significantly more likely to meet criteria for lifetime binge-eating disorder than Black patients. Black patients were significantly more likely to skip breakfast and dinner and engage in night eating than White patients.

CONCLUSIONS

Our findings suggest that among patients with LOC eating following sleeve gastrectomy surgery, there exist few racial differences in current eating-disorder psychopathology and psychosocial functioning, although Black patients achieved less weight loss than White patients.

Body mass index restrictions in fertility treatment: a national survey of OB/GYN subspecialists

PURPOSE

To explore the attitudes of reproductive endocrinology and infertility (REI) and maternal-fetal medicine (MFM) subspecialists regarding the necessity and appropriateness of body mass index (BMI) cutoffs for women seeking fertility treatment.

METHODS

Members of the Society for Reproductive Endocrinology and Infertility (SREI) and the Society for Maternal Fetal Medicine (SMFM) were invited to participate in a survey querying their knowledge of existing institutional or clinic BMI policies and personal opinions regarding upper and lower BMI cutoffs for a range of fertility treatments, including oral ovulation agents, gonadotropins, and in vitro fertilization.

RESULTS

Respondents included 398 MFMs and 201 REIs. The majority of REI and MFM providers agreed with upper limit BMI cutoffs (72.5% vs 68.2%, p = 0.29), but REIs were twice as likely to support lower limit BMI restrictions compared to MFMs (56.2% vs 28.4%, p < 0.0001). Those who supported upper BMI restrictions were more likely to be female and report existing institutional BMI cutoffs. The majority of respondents (99.3%) believed that an official statement to guide clinicians should be issued by a national professional organization.

CONCLUSIONS

Although practice patterns widely vary, the majority of REIs and MFMs believe that there should be a BMI cutoff above which women should not be offered immediate fertility treatment. Furthermore, there is a reported need for a written statement by a national professional organization to guide clinical practice and to ensure that OB/GYN subspecialists are providing consistent, fair, and safe recommendations to infertile women at the extremes of BMI.

Alignment of diet prescription to genotype does not promote greater weight loss success in women with obesity participating in an exercise and weight loss program

OBJECTIVE

Genetics contribute to variability in individual response to weight-loss interventions. The objective of this study was to determine the efficacy of a commercially available exercise and weight-loss program and whether alignment of diet to genotype related to lipid metabolism promotes greater success.

DESIGN

Sedentary women with obesity (n = 63) had genotype (FABP2rs1799883, PPARG2rs1801282, ADRB3rs4994C3, ADRB2rs1042713, rs1042714) determined using a direct-to-consumer genetic screening kit purported to promote greater weight-loss success through dietary recommendations based on these genes. Participants were randomly assigned to follow a moderate carbohydrate (MC) or lower carbohydrate (LC) hypo-energetic diet that aligned (A) or did not align (NA) with genotype for 24 weeks while participating in a resistance training and walking program. Data were analysed by general linear model repeated measures adjusted for baseline variables and are presented as mean (95% confidence interval) changes from baseline.

RESULTS

Participants in the LC group experienced greater improvements (p = 0.051, ηp 2 = 0.025) in per cent changes in body composition (weight: MC -3.32 [-1.4, -5.2], LC -5.82 [-4.1, -7.6]; fat mass: MC -7.25 [-3.2, -11.2], LC -10.93 [-7.3, -14.5]; fat-free mass: MC -0.32 [1.4, -2.0], LC -1.48 [0.7, -3.0]; and body fat percentage: MC -4.19 [-1.6, -6.8], LC -5.60 [-3.3, -7.9] %). No significant differences were observed between genotype groups (weight: A -5.00 [-3.3, -6.7], NA -4.14 [-2.2, -6.1]; fat mass: A -10.15 [-7.0, -13.6], NA -8.02 [-4.0, -12.0]; fat-free mass: A -1.23 [0.3, -2.8], NA -0.56 [1.12, -2.3]; and body fat: A -5.28 [-3.0, -7.6], NA -4.51 [-1.9, -7.1] %).

CONCLUSIONS

Adherence to this exercise and weight-loss program promoted improvements in body composition and health outcomes. While individuals following the LC diet experienced greater benefits, alignment of these diets to this genetic profile did not promote greater health outcomes.