Higher Socioeconomic Status is Associated with Improved Outcomes After Obesity Surgery Among Women in Germany

Weight loss outcomes and associated factors after metabolic bariatric surgery: Analysis of routine clinical data in Scotland

BACKGROUND

Bariatric surgery is a cornerstone intervention for individuals with severe obesity, offering substantial and sustainable weight loss.

METHODS

This retrospective cohort study included 186 patients with obesity and Type2 diabetes who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2009 and 2020 ​at University Hospital Ayr. Optimal clinical response weight loss was defined as excess weight loss (%EWL) ≥50 ​% or total weight loss (%TWL) ≥20 ​%.

RESULTS

At 2-years post-surgery, 43.6 ​% achieved ≥50 %EWL, and 44.1 ​% achieved ≥20%TWL, with 31.8 ​% maintaining this at 5-years. Depending on the definition used, between 11.2 ​% and 45.9 ​% of patients experienced recurrent weight gain. BMI had significant positive association with %TWL but negative with %EWL (p ​< ​0.05). RYGB had significantly higher %TWL compared to SG (p ​< ​0.05).

CONCLUSION

Most patients experienced weight loss which was maintained over time, however recurrent weight gain was noted. Pre-surgery BMI was significantly associated with weight changes.

Equitable Access, Lasting Results: The Influence of Socioeconomic Environment on Bariatric Surgery Outcomes

PURPOSE

Low socioeconomic status (SES) correlates with higher obesity rates and challenges in accessing treatments like bariatric surgery (BS). This study aims to assess SES's influence on medium-term BS outcomes in a setting of universal healthcare, ensuring equitable treatment access.

MATERIAL AND METHODS

We conducted a retrospective analysis of 193 BS patients (1997-2018) at a tertiary care hospital. Weight loss was expressed as change in % total weight loss (%TWL) and excess body weight (EBW) loss. Successful BS was defined as > 50% EBW loss. SES was gauged using quartiles of the Spanish Deprivation Index. A multivariable Cox regression model evaluated SES impact on BS success over follow-up.

RESULTS

The mean follow-up was 6.9 ± 4.6 years; patients averaged 43.9 ± 11.8 years, with 29.7% men. Preoperative BMI was 48.2 ± 8.2 kg/m2. At follow-up, BMI was 33.9 ± 6.6 kg/m2, with 29.3 ± 12.02% of %TWL. No SES quartile differences in BS success were noted at follow-up (log rank p = 0.960). Cox regression revealed no SES disparities in BS outcomes post-adjustment. However, female sex (HR 1.903; p = 0.009) and diabetes mellitus (HR = 0.504; p = 0.010) correlated with weight-related outcomes.

CONCLUSION

In a universal healthcare system with equitable treatment access, medium-term BS outcomes remain consistent irrespective of patients' socioeconomic status.

Mind the gap! Factors that predict progression to bariatric surgery indicate that more psychological treatment may be required

In the UK, the number of adults living with obesity is increasing. Bariatric surgery is an available treatment for those living with a BMI (kg/m2 ) ≥40 and above, or ≥35 with obesity-related comorbidities. Guidelines highlight the importance of providing psychological support pre- and post-surgery owing to the complex psychopathology present in those living with obesity. There are a lack of studies examining which patients proceed to surgery and the factors that predict progression. Routine patient data were collected within one NHS regional service in the UK, comprising 733 patients between 3 August 2018 and 26 July 2019, aged between 17 and 76 years (M = 43.20, SD = 12.32). The only exclusion criteria were patients still awaiting a final decision for surgical outcome at the point of analysis (N = 29), which resulted in 704 patients included in analysis. Binary Logistic Regression revealed those who were more likely to progress to surgery had a lower-level use of maladaptive external substances; lower level of self-harm and/or suicidality, were older in age; had a lower BMI; and had less comorbidities than those who did not progress. Findings support existing literature in that bariatric patients often present with physical and mental health complexity. Two thirds of patients in this study did not progress to surgery. Service commissioning decisions meant that these patients did not have access to psychology treatment. Consequently, in cases where bariatric surgery is considered, a final treatment option and otherwise clinically appropriate, lack of access to specialist services may result in unmet patient need owing particularly to a lack of psychological treatment provision.

The forgotten patient: A psychological perspective on the implementation of bariatric surgery guidelines

There is strong evidence demonstrating the impact of bariatric surgery on weight-loss and comorbidity improvement. In the UK, there is specific guidance to facilitate the assessment of a person's suitability for bariatric surgery. This paper highlights the clinical reality of routinely implementing this guidance, supported by literature and the perspectives of practicing psychologists. The consequences of the implementation of clinical guidelines within the context of the typical biopsychosocial profile of those referred for bariatric surgery are discussed. The ramifications of a screening approach rather than a clinical formulation-based approach to assessment, impact of a possible unconscious bias in commissioning and an overemphasis on a biomedical model approach to treatment are also presented. These contextual factors are argued to contribute to a population of "forgotten patients" that is, patients who have been assessed as not suitable for bariatric surgery, and thus "stuck" in their journey toward better health. For these individuals the only option left are energy balance only approaches, which are the very same approaches to weight-loss and comorbidity improvement that have been attempted, often for many years. Not only have these approaches not resulted in weight-loss and health improvement, they also fail to address the underlying psychological causes of obesity. Consequently, this lack of support means that patients continue to suffer from poor quality of life, with no clear pathway to improved health and wellbeing. This paper illuminates the clear gaps in weight management service provision, the implementation of guidelines in practice, and offers practical suggestions to reduce the unintended consequences of clinical guidelines for bariatric surgery.

The long weight: association between distressed communities index and long-term weight outcomes following bariatric surgery

BACKGROUND

Socioeconomic status (SES) is multifactorial, and its effect on post-bariatric weight recurrence is unclear. Distressed Community Index (DCI) is a composite SES score measuring community economic well-being. This study aims to evaluate the effect of DCI on long-term post-bariatric weight outcomes.

METHODS

Retrospective analysis of patients undergoing primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2015 and 2020 was performed. All weights in the electronic medical record (EMR), including non-bariatric visits, were captured. Patients were stratified into low tier (LT) and high tier (HT) DCI groups.

RESULTS

Of 583 patients, 431 (73.9%) were HT and 152 (26.1%) were LT. Average bariatric follow up was 1.78 ± 1.6 years and average postoperative weight in the EMR was 3.96 ± 2.26 years. Rates of bariatric follow up within the last year were similar (13.8% LT vs 16.2% HT, p = 0.47). LT had higher percent total body weight loss (%TWL; 26% LT vs 23% HT, p < 0.01) and percent excess weight loss (%EWL; 62% vs 57%, p = 0.04) at 1 year on univariate analysis. On multivariate linear regression adjusting for baseline characteristics and surgery type, there were no differences in %EWL between groups at 1 year (p = 0.22), ≥ 3 years (p = 0.53) or ≥ 5 years (p = 0.34) postop. While on univariate analysis LT only trended towards greater percentage of patients with > 15% increase from their 1-year weight (33.3% LT vs 21.0% HT, p = 0.06), on multivariate analysis this difference was significant (OR 2.0, LT 95%CI 1.41-2.84). There were no differences in the percentage of patients with > 15% decrease in %EWL from 1 to 3 + years postop between groups (OR 0.98, LT 95% CI 0.72-1.35).

CONCLUSIONS

While low tier patients had similar weight loss at 1 year, they were twice as likely to have weight recurrence at ≥ 3 years. Further studies are needed to identify factors contributing to greater weight recurrence among this population.

Socioeconomic Deprivation Is Not Associated with Outcomes after Esophagectomy at a German High-Volume Center

In Germany, socioeconomically deprived citizens more often develop esophageal carcinoma, since typical risk factors follow the social gradient. Therefore, we hypothesized that socioeconomic deprivation might also be associated with advanced tumor stages and comorbidities at the time of surgery. As a consequence, socioeconomic deprivation may be related to postoperative complications and reduced overall survival. Therefore, 310 patients who had undergone esophagectomy for cancer in curative intent between 2012 and 2020 at the University Medical Center Hamburg-Eppendorf (UKE) were included in this study. Socioeconomic status (SES) was estimated using the purchasing power of patients' postal codes as a surrogate parameter. No association was found between SES and tumor stage or comorbidities at the time of surgery. Moreover, SES was neither associated with postoperative complications nor overall survival. In conclusion, socioeconomic inequalities of patients treated at a high-volume center do not affect treatment outcomes.

Neighborhood deprivation and residential property values do not affect weight loss at 1 or 3 years after bariatric surgery

OBJECTIVE

This study examined the association between individual- and neighborhood-level sociodemographic factors and surgical weight loss at 1 year (short term) and 3 years (long term).

METHODS

Data were obtained from the baseline survey of the BELONG (Bariatric Experience Long Term) prospective longitudinal cohort study. Individual-level self-reported data on sex, race and ethnicity, education, and household income were obtained by survey. Data from the 2010 US Census were used to calculate area Neighborhood Deprivation Index score and median value of owner-occupied housing units at the census tract level.

RESULTS

Patients (N = 1341) had a mean age of 43.4 (SD 11.3) years, were mostly female (86%), were mostly Black or Hispanic (52%), had some college education (83%), and had annual household incomes ≥$51,000 (55%). Percentage total weight loss was 25.8% (SD 9.0%) at year 1 and 22.2% (SD 10.5%) at year 3. Race and ethnicity and age were significant predictors of weight loss at 1 and 3 years with a small effect of self-reported household income at year 1. There were no significant associations between census tract-level Neighborhood Deprivation Index score or value of owner-occupied housing units and weight loss at either time point.

CONCLUSIONS

Health systems could improve the chances of weight-loss maintenance after surgery by addressing factors related to racial and ethnic disparities and to income disparities.

Fatty acid-binding protein-4 (FABP4) and matrix metalloproteinase-9 (MMP9) as predictive values for nonalcoholic steatohepatitis (NASH)

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD), especially nonalcoholic steatohepatitis (NASH) increases the risk for liver cirrhosis. Noninvasive tests for NAFLD/NASH exist, but they are unreliable and thus liver biopsy remains the standard for diagnosis and new noninvasive diagnostic approaches are of great interest. The aim of this study was to test whether the serum levels of fatty acid-binding protein-4 (FABP4) and matrix metalloproteinase-9 (MMP9) could be used as a diagnostic tool for NASH.

METHODS

Patients who underwent bariatric surgery and simultaneous liver biopsy were identified. Biopsies were assigned a NAFLD activity score (NAS). MMP9- and FABP4- Enzyme-linked Immunosorbent Assays (ELISAs) on serum samples were performed. The serum levels of FABP4/MMP9 were compared and different models to predict NASH were developed.

RESULTS

A total of 84 patients were included, 28 patients (33.3%) were diagnosed with NASH. Higher concentrations of MMP9 in NASH patients (p < 0.01) were detected. FABP4 concentrations were not significantly increased. A moderate correlation between the NAS and MMP9 concentrations (r = 0.32, P < 0.01) was observed. The neural network model fit best with the dataset, with an area under the curve (AUC) of 83% and an accuracy of 88%.

CONCLUSION

Serum MMP9 levels are increased in patients with NASH and should routinely be measured in patients with obesity, but further investigations are needed to improve noninvasive NASH diagnosis.

Evaluating the Bariatric Safety Net: Analysis of Socioeconomic Factors and Outcomes at a Bariatric Safety Net Program Compared to an Affiliated Private Center

PURPOSE

Obesity is prevalent among economically disadvantaged and racially underrepresented populations. It has been suggested that socioeconomic factors, race, and lifestyle habits are important factors associated with weight loss and comorbidity remission after bariatric surgery. This study analyzes outcomes of bariatric surgery at a private hospital (PH) versus an affiliated safety-net hospital (SNH).

METHODS

Retrospective review of laparoscopic sleeve gastrectomies (LSG) performed by the same surgeons at a PH and SNH in a large metropolitan setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. A postoperative telephone survey was conducted to study dietary and lifestyle differences between cohorts.

RESULTS

Of the 243 LSG performed, 141 (58%) occurred at PH versus 102 (42%) at SNH. Most patients at SNH were Hispanic, lower socioeconomic status, and had government-sponsored insurance. Based off the results from the postoperative telephone survey, there were no significant differences in dietary and lifestyle habits between both cohorts. Postoperative weight loss outcomes were similar across cohorts. The two groups had similar percent excess weight loss (EWL) at all time points up to 36 months and similar rates of failure to achieve 50% EWL at 12 months. However, patients at PH had greater resolution of diabetes and hypertension after surgery.

CONCLUSION

Our study demonstrates outcomes after bariatric surgery are similar at a PH and its affiliated SNH. Despite differences in race and socioeconomic factors between the two cohorts, perioperative outcomes, short-term postoperative weight loss, and weight loss failure rates were equivalent between SNH and PH patients.