Comparison of outcomes after laparoscopic adjustable gastric banding in African-Americans and whites

The Role of Ethnic Disparities in the Outcomes of Bariatric Surgery: A Systematic Review and Meta-Analysis

Bariatric surgery is increasingly performed over the past decade for the treatment of morbid obesity. It has beneficial effects on weight reduction, along with diabetes remission. Conflicting results have been reported to evaluate the effect of ethics differences on the outcomes of bariatric surgery. We conducted this meta-analysis to outline the effects of ethnic differences on the outcomes of bariatric surgery, including weight reduction, biochemical variables, diabetes, and hypertension remission. A comprehensive literature search was conducted, using PubMed, Web of Science (ISI), Google Scholar, Popline, Global Health Library (GHL), Virtual Health Library (VHL) including Cochrane database, New York Academy of Medicine (NYAM), and System for Information on Grey Literature in Europe (SIGLE) for studies reporting body mass index (BMI), percentage of excess weight loss (%EWL), waist circumference, hypertension, lipid profile, and diabetes variables. We used the National Heart, Lung, and Blood Institute (NHLBI) tool (Bethesda, MD: NHLBI, National Institutes of Health {NIH}) for quality assessment. Comprehensive Meta-Analysis version 2 software (Englewood, NJ: Biostat, Inc.) was applied to perform the meta-analysis of the variables of interest. We included 23 studies of 71,679 subjects, who underwent bariatric surgery. The majority of the included cases were Whites 55,030 (77%), while 705 (1%) were Asians. The percentages of Blacks, African Americans, Hispanics, and Non-Hispanics were 9.3%, 1.3%, 10.4%, and 1%, respectively. BMI showed no significant difference between Whites vs African American and Hispanic vs Non-Hispanic groups (MD: 0.858; 95% CI: 3.408-1.691; p = 0.509 and MD: 0.455; 95% CI: 2.444-1.554; p = 0.663, respectively). The same result was reported for %EWL, comparing Whites vs African Americans. Lipid biochemical variables, diabetes remission, and hypertension control were significantly more seen among the Asian population. In conclusion, we reported a significant ethnic diversity and reduction in waist circumference, hyperlipidemia, and the associated morbidity one year after bariatric surgery in the Asian population. Further, high-quality prospective studies should focus on the social and psychological ethnic differences associated with obesity.

Racial disparities in bariatric surgery postoperative weight loss and patient satisfaction

BACKGROUND

A growing body of evidence has demonstrated racial disparities in bariatric surgery (BS) outcomes. We aimed to investigate the impact of race on postoperative percent excess weight loss (%EWL) and patient satisfaction.

METHODS

Single center retrospective study of patients who underwent BS January 2012 to November 2017. Statistical analysis utilized Chi-squared, ANOVA and multivariable regression.

RESULTS

A total of 378 patients were included. African American patients lost significantly less weight compared to Caucasian and Hispanic patients (39.0 %EWL, 53.4 %EWL and 52.3 %EWL, respectively). A significant difference remained after adjustment for possible confounders. No difference in postoperative satisfaction was found.

CONCLUSIONS

Our study adds to the existing literature demonstrating racial disparities in BS postoperative EWL, despite adjusting for possible confounders, while contributing to the limited literature examining Hispanic patients. Furthermore, we examined an understudied outcome in postoperative patient satisfaction and found no racial disparity despite disparity in EWL.

Racial disparities in bariatric surgery postoperative weight loss and co-morbidity resolution: a systematic review

While bariatric surgery is an accepted treatment for morbid obesity, the impact of race on surgical outcomes remains unclear. This systematic review aims to compare differences in weight loss and co-morbidity outcomes among various races after bariatric surgery. PubMed, Medline, and SCOPUS databases were queried to identify publications that included more than 1 racial group and reported weight loss outcomes after bariatric surgery. A total of 52 studies were included. Non-Hispanic black (NHB) patients comprised between 5.5% and 69.7% and Hispanic patients comprised between 4.7% and 65.3% of the studies' populations. Definitions of weight loss success differed widely across studies, with percent excess weight loss being the most commonly reported outcome, followed by percent total weight loss and change in body mass index (BMI). Statistical analyses also varied, with most studies adjusting for age, sex, preoperative weight, or BMI. Some studies also adjusted for preoperative co-morbidities, including diabetes mellitus, hypertension, and hyperlipidemia, or socioeconomic status, including income, education, and neighborhood poverty. The majority of studies found less favorable weight loss in NHB compared to Hispanic and non-Hispanic white (NHW), patients while generally no difference was found between Hispanic and NHW patients. The trend also indicates no association between race and resolution of obesity-related co-morbidities. Racial minorities lose less weight than NHW patients after bariatric surgery, although the factors associated with this discrepancy are unclear. The heterogeneity in reporting weight loss success and statistical analyses amongst the literature makes an estimation of effect size difficult. Generally, racial disparity was not seen when examining co-morbidity resolution after surgery. More prospective, robust, long-term studies are needed to understand the impacts of race on bariatric surgery outcomes and ensure successful outcomes for all patients, regardless of race.

Exploring racial disparity in perioperative outcomes following revisional bariatric surgery: A case-control matched analysis

INTRODUCTION

Bariatric surgery is associated with 20-30% weight recidivism. As a result, revisional bariatric operation is increasingly performed. Disparity in bariatric outcomes remains controversial and very little is known about revisional bariatric surgery outcomes in ethnic cohorts.

METHODS

Revisional bariatric cases were identified from the 2015 and 2016 Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File. 1:1 case-control matching was performed and perioperative outcomes compared between racial cohorts.

RESULTS

24,197 cases were analyzed, including 20.78% Black patients. At baseline, there were differences in demographics and pre-existing conditions between racial cohorts. Matched analysis compared 7,286 Black and White patients. Operative duration (p = 0.008) and length of stay (p = 0.0003) were longer in Black patients. Readmission (6.8% vs. 5.4%, p = 0.009) was higher in Black patients. Bleeding (0.82% vs. 0.38%, p = 0.02) and surgical site infection (SSI) (2.6% vs. 1.8%, p = 0.01) were higher in White patients.

CONCLUSION

Revisional bariatric surgery is safe. Apart from a higher rate of bleeding, SSI and readmission, outcomes were not mediated by race.

Bariatric Surgery Resistance: Using Preoperative Lifestyle Medicine and/or Pharmacology for Metabolic Responsiveness

Bariatric surgery is an effective and durable treatment for individuals with obesity and its associated comorbidities. However, not all patients meet weight loss and/or cardiometabolic goals following bariatric surgery, suggesting that some people are bariatric surgery resistant. The reason for this resistance is unclear, but potential factors, such as adiposity-derived inflammation, insulin resistance, hyperglycemia, and aerobic fitness prior to surgery, have been related to blunted surgery responsiveness. Exercise, diet, and/or pharmacology are effective at reducing inflammation and improving insulin action as well as physical function. Herein, we present data that supports the novel hypothesis that intervening prior to surgery can enhance disease resolution in people who are resistant to bariatric surgery.

A multidisciplinary approach to laparoscopic sleeve gastrectomy among multiethnic adolescents in the United States

BACKGROUND

Childhood obesity has become a serious public health problem in our country with a prevalence that is disproportionately higher among minority groups. Laparoscopic sleeve gastrectomy (LSG) is gaining attention as a safe bariatric alternative for severely obese adolescents.

STUDY DESIGN

A retrospective study on morbidly obese adolescents that underwent LSG at our institution from 2009 to 2017. Primary outcomes were weight loss as measured by change in BMI and percent excess weight loss (%EWL) at 1 year after surgery, resolution of comorbidities and occurrence of complications.

RESULTS

Thirty-eight patients, of whom 71% were female and 74% were ethnic minorities, underwent LSG between 2009 and 2016. Mean age was 16.8years, mean weight was 132.0kg and mean BMI was 46.7. There were no surgical complications. Mean %EWL was 19.4%, 27.9%, 37.4%, 44.9%, and 47.7% at 1.5, 3, 6, 9, and 12month follow up visits, respectively. Comorbidity resolution rates were 100% for hypertension and nonalcoholic fatty liver disease, 91% for diabetes, 44% for prediabetes, 82% for dyslipidemia and 89% for OSA.

CONCLUSIONS

LSG is an effective and safe method of treatment of morbid obesity in adolescents as it can significantly decrease excess body weight and resolve comorbid conditions. Further studies are needed to investigate the long-term effects of LSG in adolescents.

CLINICAL RESEARCH STUDY

Descriptive case series with prospective database.

LEVEL OF EVIDENCE

IV.

Predictors of long-term success after laparoscopic Roux-en-Y gastric bypass in African-American women

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides sustained weight loss. However, short-term studies have suggested that African Americans (AAs) are not as successful as Caucasians (CAs) after LRYGB.

OBJECTIVE

The present study was designed to test the hypothesis that at longer term follow-up AAs are just as successful as CAs after LRYGB.

SETTING

University hospital, United States.

METHODS

A nested case-control study designed to examine the effect of race as covariate in the long-term success of women undergoing LRYGB. The study matched 3 controls per case subject, and the final numbers for analyses were 78 case patients (AA) and 204 control patients (CA). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression analysis.

RESULTS

The 2 cohorts (N = 282) were well matched for age (AA 40.3±9.1 years versus CA 41.1±8.9 years), preoperative body mass index (AA 50.6±7.5 kg/m(2) versus CA 50.2±7.1 kg/m(2)), prevalence of type 2 diabetes (T2D) (AA 20.5% versus CA 21.1%), hypertension (AA 69.1% versus CA 52%), and sleep apnea (AA 35.9% versus CA 34.8%). In the AA group, the long-term curve for percentage of excess weight loss (EWL) was significantly (P<.001) lower than the CA group at any time-point. In the present model, diagnosis of T2D in the AA group (OR = 6.1 E8) significantly (P = .002) predicted adequate EWL at 3 years, after controlling for relevant confounders.

CONCLUSION

Race significantly affected the long-term EWL at 3 years for patients undergoing LRYGB at the authors' institution. Future research should be directed at determining potential genetic reasons for these differences, including genes associated with T2D.

Impaired weight loss in laparoscopic adjustable gastric banding patients over 50 years of age: diabetes mellitus as an independent risk factor

INTRODUCTION

Laparoscopic adjustable gastric banding (LAGB) represents a safe and effective bariatric procedure, particularly for patients over 50. Preoperative risk factors for impaired post-LAGB excess weight loss are not well characterized for this population. This study aimed to identify demographics, characteristics or comorbidities associated with excess weight loss at 6 and 12 months postoperatively (EWL180 and EWL365, respectively) for these patients.

METHODS

One hundred and seventeen LAGB patients >50 years of age from 2005 to 2014 were retrospectively reviewed for factors potentially associated with EWL180 and EWL365. Rationally selected variables chosen for analysis included age, race, gender, initial body mass index and preoperative weight loss; comorbidities assessed included hypertension, psychiatric disorders and diabetes mellitus (DM). Variables correlated with EWL180 or EWL365 on bivariate linear regression analysis (P ≤ .05) were input into multivariate linear regression analysis to confirm independent association.

RESULTS

Preoperative DM (B = -9.1% EWL; 95% CI -13.6, -4.5%; P < .001) and African-American race (B = -8.8% EWL; 95% CI -17.3, -0.3%; P = .05) were independent risk factors for impaired EWL180. Only DM was a risk factor for impaired EWL365 (B = -9.7% EWL; 95% CI -17.7, -1.8%; P = .02).

CONCLUSIONS

LAGB is a successful operation in patients >50 years of age. Preoperative DM is an independent risk factor for impaired EWL in this cohort.

Ethnic variation in weight loss, but not co-morbidity remission, after laparoscopic gastric banding and Roux-en-Y gastric bypass

BACKGROUND

Demographic factors such as ethnicity may affect bariatric surgery outcomes. We examined weight loss and co-morbidities outcomes in African American, Caucasian, and Hispanic patients who underwent laparoscopic gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). The primary aim was to investigate demographic differences in weight loss and co-morbidities outcomes.

METHODS

We retrospectively examined weight change and co-morbidities outcomes in our prospective database. A total of 1,903 patients underwent LAGB or RYGB between January 1, 2005 and March 31, 2012. Of those, 1828 completed their 1-year follow-up visit (9-15 mo) and had complete data. We excluded patients who were missing ethnicity information, resulting in a final cohort of 1,684 patients. Multivariate analyses and χ2 tests were used to examine demographic variables in body mass index (BMI) change, percent excess weight loss (%EWL), and remission of co-morbidities. We also examined weight loss outcomes at 2- and 3-year follow-up.

RESULTS

Overall, those who underwent RYGB had a lower BMI and greater %EWL at 1, 2, and 3 years compared to those who had undergone LAGB. Overall, African American patients had a higher postoperative BMI than either Caucasian or Hispanic patients. African American patients also showed less %EWL than Caucasian and Hispanic patients. When we examined within surgery type, ethnic differences between African American and Caucasian patients were present across all 3 years in RYGB, but there were no ethnic differences by year 3 in LAGB. Additionally, African American and Hispanic patients no longer differed by year 3 in RYGB and by year 2 in LAGB. There were no significant ethnic differences in remission of diabetes, hyperlipidemia, hypertension, and sleep apnea at 1 year.

CONCLUSION

Our study found significant ethnic differences in the postoperative BMI and %EWL, which were more pronounced in patients undergoing RYGB than LAGB at the 3-year time point. These weight loss differences did not translate to a lower rate of co-morbidities remission.

Predictors of initial weight loss after gastric bypass surgery in twelve Veterans Affairs Medical Centers

The objective of this study was to identify determinants of significant weight loss one year after gastric bypass surgery among United States veterans. Using data from the Veterans Affairs (VA) Surgical Quality Improvement Program, we identified 516 veterans who had gastric bypass surgery (24% laparoscopic) in one of twelve VA bariatric centers in 2000-2006 and one or more postoperative weight measures. The probability of losing 30% or more of baseline weight at one year was estimated via logistic regression, examining the following potential predictor variables: age, gender, race, marital status, body mass index (BMI), American Society of Anesthesiologists class, comorbidity burden, smoking status, diabetes medications taken and surgical procedure (open or laparoscopic). The 516 cases had a mean BMI of 49 kg/m(2), mean age of 51.5 years, 74% were male, 77% were Caucasian, and 55% were married. The predicted mean weight loss was 76 (95% CI: 73-79) pounds (22%) at six months and 109 (95% CI: 104-114) pounds (32%) at one-year. Based upon estimated individual trajectories of 370 patients with adequate follow-up data, 58% of the sample lost 30% or more of their baseline weight at one year; and <1% lost <10% of their baseline weight at 1 year. In the logistic regression, patients were more likely to lose 30% or more of their baseline weight if they were female (odds ratio (OR) = 2.5, p < 0.01) or Caucasian (OR = 2.3, p < 0.01). We conclude that gastric bypass surgery yields significant weight loss for most patients in Veterans Affairs Medical Centers, but is particularly effective for female and Caucasian patients.

Influence of ethnicity on the efficacy and utilization of bariatric surgery in the USA

BACKGROUND

Ethnic disparities in patterns of utilization and outcomes after Roux-en-Y gastric bypass surgery (RYGB) were examined from Bariatric Outcomes Longitudinal Database.

METHODS

Descriptive statistics were used for demographics of Whites, Blacks, or Hispanics undergoing RYGB with 1 year of follow-up, between June 2007 and October 2011. Multivariate logistic and normal regression models, controlling for baseline characteristics, examined relationships between race and outcomes. T tests were used for continuous variables and Pearson chi-square test for categorical variables.

RESULTS

Study patients (108,333) were79 % White, 12 % Black, and 9 % Hispanic. Fewer Black males underwent surgery (15 %) compared to Whites or Hispanics (∼22 %). Blacks compared to Whites were younger (42.7 ± 10.6 vs. 46.4 ± 11.6 years), heavier BMI (50 ± 9.1 vs. 47.4 ± 8.0 kg/m(2)), and more often hypertensive (57 vs. 52 %). Other comorbidities were higher in Whites. Thirty-day mortality rate was equivalent (0.23-0.26 %), but serious adverse events were higher for Blacks (3.65 %) versus Whites (3.19 %) and Hispanics (2.01 %). At 1 year, weight and comorbidity burden declined significantly but less in Blacks despite adjustment for baseline characteristics.

CONCLUSIONS

Fewer Black males underwent RYGB. Despite a smaller percent decline in BMI and comorbidities in Blacks, all races benefitted significantly from RYGB. Influence of other factors such as diet, culture, and genetics needs to be investigated further.

Effect of ethnicity on weight loss among adolescents 1 year after bariatric surgery

AIM: To investigate whether or not bariatric surgery weight outcomes vary by ethnicity in a large, nationally representative sample of adolescents.

METHODS: The Bariatric Outcomes Longitudinal Database was used for analysis and contains data on surgeries performed on adolescents from 2004 to 2010 from 423 surgeons at 360 facilities across the United States Adolescents (n = 827) between 11 and 19 years old who underwent either gastric bypass or adjustable gastric banding surgery were included in the analysis. Outcome measures included changes in anthropometric measurements [weight (kg) and body mass index] from baseline to 3 (n = 739), 6 (n = 512), and 12 (n = 247) mo after surgery.

RESULTS: A year after patients underwent either gastric bypass (51%) or adjustable gastric banding (49%) surgery, mean estimated weight loss for all ethnic groups differed by a maximum of only 1.5 kg, being 34.3 kg (95%CI: 30.0-38.5 kg) for Hispanics, 33.8 kg (95%CI: 27.3-40.3 kg) for non-Hispanic blacks, and 32.8 kg (95%CI: 30.9-34.7 kg) for non-Hispanic whites. No overall pairwise group comparisons were significant, indicating that no ethnic group had better weight loss outcomes than did another.

CONCLUSION: Bariatric surgery substantially reduces the weight of severely obese adolescents at 1 year post-procedure with little variation by ethnicity and/or gender. These results suggest that bariatric surgery is a safe and reasonable treatment for all severely obese adolescents with the appropriate indications.

Comparison of weight loss achieved after laparoscopic adjustable gastric banding between Afro-Caribbean, Caucasian and South Asian adult female patients in a London bariatric centre

INTRODUCTION

It has been shown that following laparoscopic adjustable gastric banding (LAGB) procedures, Afro-Caribbeans achieve poorer weight loss compared with Caucasians. The reasons for this are multifactorial. However, studies have been based on mainly female patients from the US and none to date have been from the UK. Furthermore, South Asians have not previously been compared. The aim of this study was to compare excess weight loss percentage (%EWL) outcomes up to five years following LAGB in Afro-Caribbean, Caucasian and South Asian females in a London-based teaching hospital.

METHODS

An analysis was carried out of prospectively collected data of female patients aged ≥16 years of Afro-Caribbean, Caucasian or South Asian origin who underwent LAGB between October 2000 and December 2011. Data included demographics, co-morbidities and anthropometrics.

RESULTS

Overall, 596 females underwent LAGB; 316 Caucasians (53.0%), 64 Afro-Caribbeans (10.8%) and 27 South Asians (4.5%) formed the majority of those who disclosed ethnicities. Age and initial body mass index (BMI) were comparable between Afro-Caribbeans and Caucasians (mean BMI: 47.3kg/m²[standard deviation [SD]: 7.5kg/m², range: 37.0-78.3kg/m²] vs 45.8kg/m²[SD: 7.1kg/m², range: 24.7-79.8kg/m²], p=0.225). A non-significant trend suggested less %EWL in Afro-Caribbeans than in Caucasians at 6 months, and at 1, 2, 3, 4 and 5 years (21.4% vs 24.4%, p=0.26; 27.4% vs 31.3%, p=0.27; 33.0% vs 36.8%, p=0.15; 39.0% vs 45.8%, p=0.14; 34.2% vs 45.3%, p=0.16; 37.1% vs 47.6%, p=0.67). South Asians and Caucasians had a similar age and preoperative BMI (mean BMI: 43.6kg/m² [range: 32.5-59.1kg/m²] vs 45.8kg/m² [range: 24.7-79.8kg/m²], p=0.08). The %EWL was greatest at three and four years among South Asians although numbers were small (n=4 and n=3 respectively).

CONCLUSIONS

A non-significant trend suggests poorer weight loss outcomes in Afro-Caribbeans compared with Caucasians in our cohort. Discussion of realistic weight loss outcomes as well as enhanced follow-up and dietary modifications are required for Afro-Caribbean patients. Low numbers prevent definitive conclusions regarding South Asians. Multicentre studies across England are required to better define any differences between ethnicities.

Racial differences in weight loss, payment method, and complications following Roux-en-Y gastric bypass and sleeve gastrectomy

OBJECTIVES

Obesity affects approximately one-third of the US adult population. Although more black adults are considered to be obese compared to white adults, black adults are less likely to undergo bariatric surgery for weight loss. Black adults typically lose less weight and are more prone to adverse events following bariatric surgery than white adults. The objectives of this study were to compare weight loss, payment methods, and early postoperative complications between black and white adults.

DESIGN

A retrospective chart review of 420 Roux-en-Y gastric bypass (RYGB) patients and 454 sleeve gastrectomy (SG) patients (all female) was conducted. A mixed-model analysis was used to assess statistical significance of differences in weight loss between surgeries and races. A Chi-square test was used to assess racial differences in payment method (insurance or private pay) and postoperative complications by operation. Statistical significance was set as P > 0.05.

RESULTS

RYGB patients lost significantly more weight at 26, 52, 78, and 104 weeks postoperatively compared to SG patients. White females (WF) lost significantly more weight than black females (BF) at 26, 52, 78, and 104 weeks postoperatively. WF experienced more minor and major complications in the perioperative period than BF, but BF experienced more minor and overall complications in the postoperative period than WF. A greater percentage of black patients had insurance coverage compared to white patients for both surgeries.

CONCLUSION

WF appear to lose more weight than BF regardless of surgery, but both races experience surgical complications. Black patients may be less likely to undergo bariatric surgery without insurance coverage.

Ethnic differences in weight loss and diabetes remission after bariatric surgery: a meta-analysis

OBJECTIVE

It has been postulated that the effectiveness of bariatric surgery varies between ethnic groups. However, data regarding this topic are inconclusive, as most studies included few patients from minority groups. We conducted a meta-analysis to determine the difference in percentage of excess weight loss (%EWL) 1-2 years after bariatric surgery in people of African and Caucasian descent. We also studied differences in diabetes mellitus (DM) remission.

RESEARCH DESIGN AND METHODS

We performed a MEDLINE and EMBASE search for studies reporting %EWL and/or DM remission after bariatric surgery and including both African Americans and Caucasians. The 613 publications obtained were reviewed. We included 14 studies (1,087 African Americans and 2,714 Caucasians); all provided data on %EWL and 3 on DM remission. We extracted surgery type, %EWL, and DM remission 1-2 years after surgery. After analyzing %EWL for any surgery type, we performed subanalyses for malabsorptive and restrictive surgery.

RESULTS

The overall absolute mean %EWL difference between African Americans and Caucasians was -8.36% (95% CI -10.79 to -5.93) significantly in favor of Caucasians. Results were similar for malabsorptive (-8.39% [-11.38 to -5.40]) and restrictive (-8.46% [-12.95 to -3.97]) surgery. The remission of DM was somewhat more frequent in African American patients than in Caucasian patients (1.41 [0.56-3.52]). However, this was not statistically significant.

CONCLUSIONS

In %EWL terms, bariatric surgery is more effective in Caucasians than in African Americans, regardless of procedure type. Further studies are needed to investigate the exact mechanisms behind these disparities and to determine whether ethnic differences exist in the remission of comorbidities after bariatric surgery.

Dietary interventions for weight loss and cardiovascular risk reduction in people of African ancestry (blacks): a systematic review

Objective

To systematically review weight and cardiovascular risk reduction in blacks by diet and lifestyle changes.

Design

Randomised and non-randomised controlled trials of diet with/without lifestyle changes with duration of intervention ≥3 months, and published between January 1990 and December 2009, were searched in electronic databases including MEDLINE, EMBASE, CINAHL and CCTR (Cochrane Controlled Trials Register). Studies were included if they reported weight/BMI changes with changes in at least one of the following: systolic and diastolic blood pressure, fasting plasma lipids and glucose, and glycated haemoglobin.

Setting

Clinical, community and church-based interventions.

Subjects

Study participants were of African ancestry (blacks).

Results

Eighteen studies met the inclusion criteria. Average mean difference in weight loss was −2·66 kg, with improvements in all outcomes except total cholesterol. No significant difference was observed in outcome measures between all studies and studies that recruited only healthy participants or patients with type 2 diabetes.

Conclusions

Diet and lifestyle changes result in weight loss with improvements in cardiovascular risk factors in blacks. However, more culturally tailored programmes have been suggested to motivate and encourage blacks to participate in intervention trials.

Pharmacotherapy for overweight/obesity in ethnic minorities and White Caucasians: a systematic review and meta-analysis

Ethnic minorities in the West exhibit a higher prevalence of obesity and also under-achieve in weight management compared to White Caucasians. A systematic review of randomized controlled trials (RCTs) in adults (mean age ≥18 years, duration ≥6 months and published in the English language) was undertaken to evaluate the effectiveness of antiobesity drugs in ethnic minorities and White Caucasians. Data sources between 1990 and 2010 were searched including MEDLINE, EMBASE, Cochrane Controlled Trials Register, CINAHL and references cited in the included studies of other reviews. Eighteen RCTs that met the inclusion criteria were included in this review (6 sibutramine and 12 orlistat). A random effects model was used for meta-analysis. An indirect comparison of weight loss in sibutramine-treated patients in ethnic minorities was significantly lower than in White Caucasians: -2.7 kg (95% CI: -3.1 to -2.3) versus -4.4 kg (95% CI: -5.0 to -3.8), respectively. For orlistat, weight loss was similar in the two groups: -2.3 kg (95% CI: -2.6 to -2.0) in ethnic minorities and -2.8 kg (95% CI: -5.1 to -0.5) in White Caucasian participants. Overall, there were few studies of weight loss pharmacotherapy for comparison of this review and it was not possible to analyse data based on ethnic groupings. More ethnically tailored studies are needed to assess the most effective weight loss strategies in these most metabolically vulnerable groups.

Obesity management interventions: a review of the evidence

The burden of disease associated with the obesity epidemic shortens lives, and prevalence is accelerating. As with other chronic diseases, improved outcomes are associated with effective self-management of obesity across the life span. The disease of obesity, then, fits squarely within the disease management and chronic care models. This article reviews selected interventions, described in peer-reviewed literature, designed to achieve significant weight loss for individuals identified as overweight or obese. The study objective is to provide an overview of the full range of methods and models for weight loss, including some available without medical supervision. The intended audience includes individuals and organizations with an expressed interest in disease management and the chronic care models. Our review identified promising lines of investigation for future research that span diverse medical disciplines applied to obesity. The quality of the studies included in our review was uneven, and compromises the current evidence for effectiveness and efficacy. Generally, our results showed that combination approaches-surgical or pharmacologic, combined with a behavioral intervention-were most likely to be effective.

Bariatric surgery for the treatment of morbid obesity: a meta-analysis of weight loss outcomes for laparoscopic adjustable gastric banding and laparoscopic gastric bypass

Bariatric surgery has emerged as an important tool in the fight against morbid obesity. However, reviewers have noted that there is a scarcity of long-term clinical surveillance data for bariatric surgery beyond 1-year follow-up and that a high percentage of patients are lost to follow-up, raising questions regarding the accuracy of current outcomes estimates. A meta-analysis of clinical reports providing bariatric surgery weight loss outcomes for morbidly obese patients was conducted over the period 2003-2007. Studies included were randomized controlled trials, nonrandomized controlled trials, and consecutive case series involving patients receiving either laparoscopic adjustable gastric banding (LAGB) or laparoscopic gastric bypass (LGB) surgery. Included studies involved n = 7,383 patients and were largely academic hospital-based (78.6%) and retrospective in design (71.4%). Weight loss outcome was defined by percent excess weight loss (%EWL). Composite estimates showed a significantly greater %EWL for LGB surgery (62.6%) compared to LAGB (49.4%). The superiority of LGB persisted at all three postsurgical time points examined (1, 2, and >3 years). Problems were identified regarding incomplete or suboptimal data reporting in many studies reviewed, and high patient attrition was evident at 2-year (49.8% LAGB, 75.2% LGB) and >3-year (82.6% LAGB, 89% LGB) end points. This meta-analysis confirms the superiority of LGB to LAGB in %EWL found in earlier studies. Although problems in study quality raised significant concerns regarding the validity of current weight loss estimates in this area, there was no evidence of publication bias.

Perioperative safety in the longitudinal assessment of bariatric surgery

BACKGROUND

To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization.

METHODS

We performed a prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007. A composite end point of 30-day major adverse outcomes (including death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital) was evaluated among patients undergoing first-time bariatric surgery.

RESULTS

There were 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; 10.9% nonwhite; median body-mass index [the weight in kilograms divided by the square of the height in meters], 46.5). More than half had at least two coexisting conditions. A Roux-en-Y gastric bypass was performed in 3412 patients (with 87.2% of the procedures performed laparoscopically), and laparoscopic adjustable gastric banding was performed in 1198 patients; 166 patients underwent other procedures and were not included in the analysis. The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; a total of 4.3% of patients had at least one major adverse outcome. A history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status were each independently associated with an increased risk of the composite end point. Extreme values of body-mass index were significantly associated with an increased risk of the composite end point, whereas age, sex, race, ethnic group, and other coexisting conditions were not.

CONCLUSIONS

The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese. (ClinicalTrials.gov number, NCT00433810.)

African Americans' perceptions of physician attempts to address obesity in the primary care setting

BACKGROUND

Obesity disproportionately affects African Americans and leads to several major co-morbidities. While guidelines recommend physicians identify obese patients and counsel them on weight management, little is known about how these efforts are received by patients.

OBJECTIVE

To elucidate how obese, urban African American patients perceive the physician role in the treatment of obesity and to identify specific provider behaviors that may motivate or hinder attempts at weight loss.

DESIGN

Qualitative study involving eight focus groups.

PARTICIPANTS

Forty-three obese African-American patients recruited from academic internal medicine practices participated in focus groups between September 2007 and February 2008.

MEASUREMENTS AND MAIN RESULTS

Four broad themes emerged: (1) dislike of the word obese, (2) importance of the physician manner and timing when discussing weight, (3) necessity of a personalized approach in discussing weight management issues, and (4) variable response to scare tactics. Within each theme participants identified specific physician behaviors that were perceived as either motivating or hindering attempts at weight loss.

CONCLUSIONS

Physicians must be cognizant of the potential unintended consequences of the techniques they use to educate and counsel African-American men and women on obesity, particularly those that may be perceived as negative and act to further alienate obese patients from seeking the care they need.

Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2

BACKGROUND

Many mildly to moderately obese individuals with a body mass index (BMI) lower than 35 kg/m(2) have serious diseases related to their obesity. Nonsurgical therapy is ineffective in the long term, yet surgery has never been made widely available to this population.

METHODS

Between 2002 and 2007, 53 patients with a BMI lower than 35 kg/m(2) underwent laparoscopic adjustable gastric banding at our institution. Data on all these patients were collected prospectively and entered into an institutional review board-approved electronic registry. The study parameters included preoperative age, gender, BMI, presence of comorbidities, percentage of excess weight loss (%EWL), and resolution of comorbidities.

RESULTS

The mean preoperative age of the patients was 46.9 years (range, 16-68 years), and the mean preoperative BMI was 33.1 kg/m(2) (range, 28.2-35.0 kg/m(2)). Of the 53 patients, 49 (92%) had at least one obesity-related comorbidity. The mean BMI decreased to 28.1 +/- 2.4 kg/m(2), 25.8 +/- 2.9 kg/m(2), and 25.8 +/- 3.1 kg/m(2) and mean %EWL was 48.3 +/- 17.6, 69.9 +/- 28.0, and 69.7 +/- 31.7 at 0.5, 1, and 2 years, respectively. Substantial improvement occurred for the following comorbidities evaluated: hypertension, depression, diabetes, asthma, hypertriglyceridemia, obstructive sleep apnea, hypercholesterolemia, and osteoarthritis. There was one slip, two cases of band obstruction (from food), two cases of esophagitis, and two port leaks, but no mortality.

CONCLUSION

The authors are very encouraged by this series of low-BMI patients who underwent laparoscopic adjustable gastric banding. Their weight loss has been excellent, and their complications have been acceptable. Their comorbidities have partially or wholly resolved. With further study, it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m(2).

Relationship of body mass index with demographic and clinical characteristics in the Longitudinal Assessment of Bariatric Surgery (LABS)

BACKGROUND

The relationship between body mass index (BMI) and demographic/clinical characteristics of patients undergoing bariatric surgery is poorly characterized. BMI is often used to characterize patient risk in bariatric surgery. However, its relationship with other risk factors has not been well characterized.

METHODS

The Longitudinal Assessment of Bariatric Surgery-1 was a study of the 30-day outcomes in patients undergoing bariatric procedures at 10 clinical centers in the United States. The sample for this study included participants with a BMI > or =40 kg/m(2) and no history of undergoing a bariatric procedure from March 1, 2005 to March 26, 2007. This analysis examined the relationships between BMI strata and several demographic/clinical characteristics.

RESULTS

Of 2559 patients (23% male, 10% black, 9% age > or =60 yr) with a BMI of > or =40 kg/m(2), 29% had a BMI of 50 to <60 kg/m(2) and 12% a BMI of > or =60 kg/m(2). The percentage of men and blacks increased with greater BMI category and the percentage of older patients (age > or =60 yr) decreased. Patients with a greater BMI were more likely to have a history of several co-morbid conditions (hypertension, diabetes, congestive heart failure, asthma, poor functional status, sleep apnea, pulmonary hypertension, venous thromboembolism, or venous edema with ulcerations) than were patients with a BMI of 40-50 kg/m(2) after adjusting for age, race, sex, and ethnicity.

CONCLUSION

A greater BMI was associated with several patient characteristics that have been linked to less weight loss, more adverse outcomes, and increased healthcare use in previous studies. Outcomes analyses should consider the potential for the confounding of BMI with demographic and clinical characteristics.

Predictors of weight loss and effectiveness of Roux-en-Y gastric bypass in the morbidly obese Hispano-American population

BACKGROUND

Co-morbidities and the metabolic response to intervention in morbid obesity have been reported to vary among different ethnic groups. We compared the rate of weight loss, effectiveness of gastric bypass surgery, and variables influencing success after gastric bypass in Hispanics compared to Caucasians.

METHODS

Morbidly obese adult (>18 years old) patients (body mass index [BMI] 40 or above) evaluated by our bariatric group from 2005 to 2006 who underwent Roux-en-Y gastric bypass (RYGBP) were studied. Every patient was evaluated for height, weight, BMI, percent body fat, fat mass, serum metabolic analysis (SMA) 12, lipid profile, complete blood count (CBC), iron, ferritin, Vitamins A, D, and B1, complete urinalysis and Fibrospect score II. Weight loss was evaluated at 1, 3, 6, and 12 months.

RESULTS

Seventy-five patients underwent successful open RYGBP with no mortality. Regardless of the significant difference in age and co-morbidities, the mean percentage of total weight loss after 1 year of follow-up was 32% for Hispanics and 30% for Caucasians with no significant difference (p > .5). When comparing the percentage of excess weight lost (% EWL) at 1, 3, 6, and 12 months, there was no significant difference between both groups. Using multiple regression analysis, we found that high-density lipoprotein (HDL) and systolic blood pressure (SBP) significantly predicted EWL at 12 months in Caucasians and Fibrospect predicted significantly EWL at 1 year.

CONCLUSION

At 1 year after RYGBP, both ethnic groups lost approximately 77-80% of their EWL and BMI. All Caucasians and 95.7% of Hispanics achieved successful weight loss (>50% EWL).

The impact of race on weight loss after Roux-en-Y gastric bypass surgery

BACKGROUND

Gastric bypass surgery for morbid obesity has dramatically increased in volume over the past decade. Caucasian patients have been noted previously to lose more weight after bariatric surgery than African-Americans patients. Data regarding predictors of maintaining weight loss after surgery are minimal. We sought to determine predictors of long-term weight loss after bariatric surgery.

METHODS

Retrospective analysis using a multivariate logistic regression model of all patients undergoing Roux-en-Y gastric bypass surgery at the Medical University of South Carolina from May 1993 to December 2004 for whom 2 years of follow-up data was available. Our dependent variable was the percentage of weight lost from baseline, dichotomized at +/-35%. Our primary independent variable was race, defined as Caucasian, African-American, or other. Relevant covariates were added to the model to control for their potential effects on outcome.

RESULTS

One hundred eleven patients (17 male/94 female; 85% Caucasian, mean age 44 years (range 18-68 years). In our model, Caucasian subjects (adjusted odds ratio [OR] = 7.60, 95% confidence intervals [95%CI] = 1.83-31.5) and late post surgical complications (adjusted OR = 2.67, 95%CI = 1.05-6.80) significantly predicted weight loss at 2 years, after controlling for relevant confounders. Other covariates did not significantly impact the model.

CONCLUSION

Race and late post surgical complications significantly impacted the percentage of weight loss at 2 years for patients undergoing Roux-en-Y gastric bypass surgery at our institution. Future research should be directed at determining potential genetic and/or social reasons for these differences.

Surgical treatment of obesity

Obesity is very prevalent. Most treatments fail owing to hard-wired survival mechanisms, linking stress and appetite, which have become grossly maladaptive in the industrial era. Antiobesity (bariatric) surgery is a seemingly drastic, efficacious therapy for this serious disease of energy surfeit. Technical progress during the last two decades has greatly improved its safety. The surgical principles of gastric restriction and/or gastrointestinal diversion have remained largely unchanged over 40 years, although mechanisms of action have been elucidated concomitant with advances in knowledge of the molecular biology of energy balance and appetite regulation. Results of bariatric surgery in large case-series followed for at least 10 years consistently demonstrate amelioration of components of the insulin-resistance metabolic syndrome and other comorbidities, significantly improving quality of life. Furthermore, bariatric surgery has convincingly been demonstrated to reduce mortality compared with nonoperative methods. This surgery requires substantial preoperative and postoperative evaluation, teaching, and monitoring to optimize outcomes. In the absence of effective societal changes to restore a healthy energy balance, bariatric surgery is an important tool for treating a very serious disease.