Weight loss and health outcomes in African Americans and whites after gastric bypass surgery

Perceptions and Beliefs About Obesity and Bariatric and Metabolic Surgery Among Black and White Men

BACKGROUND

Although metabolic and bariatric surgery (MBS) is a safe and effective procedure to reduce severe obesity and is covered by most health insurance plans, utilization of MBS is significantly lower among men compared to women. This study identifies unique factors that explain men's attitude towards MBS.

METHODS

The study survey (paper/online) included 129 Black and White men with severe obesity from metropolitan communities in Western New York. Bivariate and multivariate analyses were used to evaluate participants' personal and community factors influencing their consideration of MBS.

RESULTS

Men willing to undergo MBS had lower education (38% vs. 21% ≤ high school, p < 0.05), were less likely to be satisfied with their body weight (27% vs. 48%, p < 0.05), more likely to have a physician supporting their weight loss efforts (55% vs. 32%, p = 0.03) and discussing MBS treatment (39% vs. 19%, p = 0.02), believed that community role models who underwent MBS "lost weight and looked great" (66% vs. 40%, p = 0.02) and that MBS was safe and effective (40% vs. 13%, p < 0.01), compared to men unwilling to undergo MBS. When adjusted for education level, dissatisfaction with body size (odds ratio, OR = 4.56, 95% confidence interval, CI: 1.16, 18.01) and physician support (OR = 3.71, 95% CI: 1.17, 11.78) remained significantly associated with men's willingness to undergo MBS. Race and BMI were not associated with willingness to undergo MBS.

CONCLUSIONS

Positive attitude toward MBS among men is influenced by self-perception of excess weight, strong physician support and community role models. Improving patient-provider communication about MBS and awareness from community role models may improve MBS utilization among men.

Race and Sex Disparities in Metabolic/Bariatric Surgery over 20 Years: A Cohort Study

Objectives

To determine how rates of discussion of metabolic and bariatric surgery (MBS) between patients with class 2 obesity and higher and their healthcare providers as well as subsequent progression to MBS have varied by race and sex over the last 20 years.

Background

Obesity is a growing public health crisis. MBS remains the most effective treatment for long-term management of obesity.

Methods

Retrospective cohort study of electronic health records from a large tertiary academic health system using a previously validated natural language processing algorithm. The primary outcomes were discussion of MBS between eligible patients and providers and progression to surgery. Multivariable logistic regression was used to determine the association between sociodemographic factors, time, and discussion and receipt of MBS.

Results

Among 122,487 patients included in the analysis, 11,094 (9.1%) patients discussed MBS with their providers. Of these, 1348 (12.2%) progressed to MBS. Between 2000 and 2020 the annual fraction of patients who had a discussion of MBS with their providers rose from 3.2% to 10.0% (P < 0.001). Black people were equally likely to discuss MBS with providers as non-Black people (9.5 vs 9.0%, P = 0.09) but were less likely to progress to MBS (8.4 vs 12.6%, P < 0.001). These disparities in progression narrowed over the study period (P = 0.044). Men were less likely than women to both discuss (8.1% vs 9.6%, P < 0.001) and receive MBS (7.6% vs 14.6%, P < 0.001), and these disparities increased over the study period.

Conclusions

Interventions to reduce racial disparities in utilization of MBS should focus on progression from discussion to MBS. Interventions to increase the uptake of MBS among men are required across the care cascade.

Associations between Adolescent Preoperative Mental Health, Psychosocial Factors, and Body Mass Index

BACKGROUND

There is little research on adolescent bariatric surgery and mental health (depression, anxiety, etc.) with racial/ethnic minority adolescents. The objective of this study is to determine associations between adolescents' preoperative reports of depression, anxiety, and self-esteem and caregiver's' reports of the caregiver-adolescent relationship and interpersonal relationships with adolescents' BMI and differences based on race/ethnicity.

METHOD

Adolescents (ages 12-21) who underwent metabolic and bariatric surgery from June 2020 to November 2022 had their responses to specific items on the BASC-3 (anxiety, depression, and self-esteem) analyzed for associations with their body mass index (BMI) and with caregiver responses to the BASC-3 for adolescents' interpersonal skills and relationship with caregiver. Demographic differences on the BASC-3 were assessed. Pearson's correlations, independent t-tests, and ANOVA were used.

RESULTS

Caregivers who had higher t-scores for relationship with their adolescents had adolescents who had lower depression t-scores, lower anxiety t-scores, and higher self-esteem t-scores. Parents who had higher t-scores for their adolescents' interpersonal relations had adolescents who had lower depression t-scores, lower anxiety t-scores, and higher self-esteem t-scores. White adolescents had higher depression t-scores than Black and Hispanic adolescents. Black and Hispanic adolescents had higher self-esteem t-scores compared to White adolescents.

DISCUSSION

Some of the findings within the study regarding adolescents' race and ethnicity and mental health are not consistent with prior research, affirming the need for additional research of these sub-populations.

Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

Variation by race/ethnicity in the utilization and weight loss following metabolic bariatric surgery

BACKGROUND

Understanding the disparities in utilization and weight loss outcomes of metabolic and bariatric surgery (MBS) by demographics will inform strategies targeting potential treatment gaps and enhance overall clinical obesity treatment.

OBJECTIVE

To identify factors associated with utilization and longitudinal weight loss after MBS.

SETTING

OneFlorida Clinical Research Consortium Database.

METHODS

We performed a retrospective study using data from the OneFlorida Clinical Research Consortium between 2012 and 2018. We used logistic regression with intersectional effects to identify factors associated with utilization of MBS. Mixed-effect models were used to estimate longitudinal percentage total weight loss among those who underwent MBS with up to 18 months of follow-up.

RESULTS

Among 429,821 patients eligible for MBS, 8290 (1.9%) underwent MBS between 2012 and 2018. Intersectional analysis revealed that non-Hispanic Black patients experienced an inferior utilization of MBS compared with non-Hispanic White and Hispanic counterparts, defined by the interaction between race/ethnicity and demographic factors, including male sex, older age, and insurance coverage. In the longitudinal weight loss assessment, 4016 patients (48.3% Roux-en-Y gastric bypass, 51.7% sleeve gastrectomy) were included. We found that non-Hispanic Black patients experienced significantly less weight loss than non-Hispanic White and Hispanic counterparts. Other factors associated with less weight loss over time included undergoing sleeve gastectomy, male sex, lower preoperative body mass index, and having type 2 diabetes at the time of surgery.

CONCLUSIONS

Our findings will help to design new strategies focusing on the intersection of race/ethnicity and sociodemographic factors to improve access and effectiveness of MBS.

Weight loss maintenance after bariatric surgery

Metabolic and bariatric surgery (MBS) is an effective treatment for patients with morbid obesity and its comorbidities. However, many patients experience weight regain (WR) after achieving their nadir weight. Establishing the definition of WR is challenging as postoperative WR has various definitions. Risk factors for WR after MBS include anatomical, racial, hormonal, metabolic, behavioral, and psychological factors, and evaluating such factors preoperatively is necessary. Long-term regular follow-up and timely treatment by a multidisciplinary team are important because WR after surgery is multi-factorial. Although lifestyle interventions that focus on appropriate dietary education, physical activity education or interventions, and behavioral psychological interventions are suggested, more well-designed studies are needed because studies evaluating intervention methods and the effectiveness of WR prevention are lacking. Anti-obesity drugs can be used to prevent and manage patients with WR after MBS; however, more research is needed to determine the timing, duration, and type of anti-obesity drugs used to prevent WR.

Prehabilitation of overweight and obese patients with dysglycemia awaiting bariatric surgery: Predicting the success of obesity treatment

Bariatric surgery offers the best health results in overweight and obese patients but is not a risk and/or complication-free treatment. In cases with additional hyperglycemia, the burden of surgery can be even higher and alter both short-term and long-term outcomes. Although bariatric surgery offers glycemic improvements and in the case of early onset diabetes disease remission, weight loss results are lower than for obese patients without diabetes. Different multimodal programs, usually including interventions related to patients' performance, nutritional and psychological status as well as currently available pharmacotherapy before the surgery itself might considerably improve the immediate and late postoperative course. However, there are still no clear guidelines addressing the prehabilitation of obese patients with dysglycemia undergoing bariatric surgery and therefore no unique protocols to improve patients' health. In this minireview, we summarize the current knowledge on prehabilitation before bariatric surgery procedures in patients with obesity and dysglycemia.

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.

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.

Development and validation of a scoring system for pre-surgical and early post-surgical prediction of bariatric surgery unsuccess at 2 years

Bariatric surgery (BS) is an effective treatment for morbid obesity. However, a simple and easy-to-use tool for the prediction of BS unsuccess is still lacking. Baseline and follow-up data from 300 consecutive patients who underwent BS were retrospectively collected. Supervised regression and machine-learning techniques were used for model development, in which BS unsuccess at 2 years was defined as a percentage of excess-weight-loss (%EWL) < 50%. Model performances were also assessed considering the percentage of total-weight-loss (%TWL) as the reference parameter. Two scoring systems (NAG-score and ENAG-score) were developed. NAG-score, comprising only pre-surgical data, was structured on a 4.5-point-scale (2 points for neck circumference ≥ 44 cm, 1.5 for age ≥ 50 years, and 1 for fasting glucose ≥ 118 mg/dL). ENAG-score, including also early post-operative data, was structured on a 7-point-scale (3 points for %EWL at 6 months ≤ 45%, 1.5 for neck circumference ≥ 44 cm, 1 for age ≥ 50 years, and 1.5 for fasting glucose ≥ 118 mg/dL). A 3-class-clustering was proposed for clinical application. In conclusion, our study proposed two scoring systems for pre-surgical and early post-surgical prediction of 2-year BS weight-loss, which may be useful to guide the pre-operative assessment, the appropriate balance of patients' expectations, and the post-operative care.

Evaluation of Dietary Assessment Tools Used in Bariatric Population

Severe obesity is associated with major health issues and bariatric surgery is still the only treatment to offer significant and durable weight loss. Assessment of dietary intakes is an important component of the bariatric surgery process. Objective: To document the dietary assessment tools that have been used with patients targeted for bariatric surgery and patients who had bariatric surgery and explore the extent to which these tools have been validated. Methods: A literature search was conducted to identify studies that used a dietary assessment tool with patients targeted for bariatric surgery or who had bariatric surgery. Results: 108 studies were included. Among all studies included, 27 used a dietary assessment tool that had been validated either as part of the study per se (n = 11) or in a previous study (n = 16). Every tool validated per se in the cited studies was validated among a bariatric population, while none of the tools validated in previous studies were validated in this population. Conclusion: Few studies in bariatric populations used a dietary assessment tool that had been validated in this population. Additional studies are needed to develop valid and robust dietary assessment tools to improve the quality of nutritional studies among bariatric patients.

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.

Methodological issues in assessing change in dietary intake and appetite following gastric bypass surgery: A systematic review

Gastric bypass surgery is an effective long-term treatment for individuals with severe obesity. Changes in appetite, dietary intake, and food preferences have all been postulated to contribute to postoperative body weight regulation, however, findings are inconsistent. The aim of this systematic review was to evaluate the current literature on changes in dietary intake and appetite following gastric bypass surgery, in the context of the methodology used and the analysis, interpretation, and presentation of results. Four databases were systematically searched with terms related to "gastric bypass surgery," "appetite," and "dietary intake," and 49 papers (n = 2384 patients after gastric bypass) were eligible for inclusion. The evidence indicated that only a reduction in overall energy intake and an increase in postprandial satiety are maintained beyond 6-month post-surgery, whereas relative macronutrient intake and premeal hunger remain unchanged. However, available data were limited by inconsistencies in the methods, analysis, presentation, and interpretation of results. In particular, there was a reliance on data collected by subjective methods with minimal acknowledgment of the limitations, such as misreporting of food intake. There is a need for further work employing objective measurement of appetite and dietary intake following gastric bypass surgery to determine how these mechanisms may contribute to weight regulation in the longer term.

Racial Disparity in 30-Day Outcomes of Metabolic and Bariatric Surgery

Background

There is evidence of racial disparity in the long-term weight loss outcomes of bariatric surgery. However, there has been a more limited evaluation of the impact of race on immediate perioperative outcomes. The aim of this study was to compare 30-day postoperative outcomes among different races.

Study Design

The 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried to identify patients aged ≥ 18 and body mass index ≥ 35 who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with known information on race. We then evaluated the effect of five different races on four different 30-day outcomes.

Results

Of the total 106,932 patients (79.5% White, 19.3% African American (AA), 0.5% Asian, 0.4% American Indian or Alaska Native, 0.3% Native Hawaiian or other Pacific Islander), 30-day rates of postoperative complication, readmission, re-intervention, and reoperation were 6, 3.8, 1.3, and 1.2%, respectively. After controlling for other covariates in multivariate logistic regression and selecting White as reference, AA was the only race associated with a higher risk of postoperative complications (odds ratio [OR] 1.13; confidence interval [CI] 1.06–1.2) and readmissions (OR 1.47; CI 1.3–1.6). AA and American Indian or Alaska Native were also associated with higher re-interventions (OR 1.31; CI 1.15–1.51 and OR 2.11; CI 1.03–4.34). Furthermore, AA was associated with lower 30-day reoperations (OR 0.83; CI 0.7–0.9).

Conclusion

This study found significant racial differences in short-term outcomes following bariatric surgery. Factors underlying these disparities are unclear and warrant further investigation.

Approach to the Patient: Management of the Post-Bariatric Surgery Patient With Weight Regain

CONTEXT

Weight regain (WR) after bariatric surgery is emerging as a common clinical problem due to the increase in the number of procedures performed. Early interventions are necessary to curtail the potential recurrence of comorbid conditions. However, it is often difficult to recognize WR early enough to introduce mitigating measures because there are no current guidelines for timely diagnosis and assessment of the severity of this condition.

OBJECTIVE

We present a practical approach for the early recognition of WR, based on 11-year follow-up data from our multiethnic bariatric surgery patient population.

METHODS

We classify WR according to the rate of increase in weight relative to nadir weight, normalized per 30-day interval. We also review pertinent literature about the etiologic factors contributing to WR after bariatric surgery.

RESULTS

According to our algorithm, mild, moderate, and rapid WR are defined as weight increases of 0.2% to <0.5%, 0.5% to 1.0%, and more than 1.0% of nadir weight per 30 days, respectively. Treatment options, including dietary counseling, use of antiobesity medication, and consideration of surgical revision, are described. A case is presented to illustrate the utility of timely identification of WR and the importance of collaboration between bariatric surgeons, obesity medicine specialists, and dietitians.

CONCLUSION

Our approach emphasizes the importance of regular long-term follow-up for all bariatric surgery patients.

The association between socioeconomic factors and weight loss 5 years after gastric bypass surgery

INTRODUCTION

Patients with low socioeconomic status have been reported to have poorer outcome than those with a high socioeconomic status after several types of surgery. The influence of socioeconomic factors on weight loss after bariatric surgery remains unclear. The aim of the present study was to evaluate the association between socioeconomic factors and postoperative weight loss.

MATERIALS AND METHODS

This was a retrospective, nationwide cohort study with 5-year follow-up data for 13,275 patients operated with primary gastric bypass in Sweden between January 2007 and December 2012 (n = 13,275), linking data from the Scandinavian Obesity Surgery Registry, Statistics Sweden, the Swedish National Patient Register, and the Swedish Prescribed Drugs Register. The assessed socioeconomic variables were education, profession, disposable income, place of residence, marital status, financial aid and heritage. The main outcome was weight loss 5 years after surgery, measured as total weight loss (TWL). Linear regression models, adjusted for age, preoperative body mass index (BMI), sex and comorbid diseases were constructed.

RESULTS

The mean TWL 5 years after surgery was 28.3 ± 9.86%. In the adjusted model, first-generation immigrants (%TWL, B -2.4 [95% CI -2.9 to -1.9], p < 0.0001) lost significantly less weight than the mean, while residents in medium-sized (B 0.8 [95% CI 0.4-1.2], p = 0.0001) or small towns (B 0.8 [95% CI 0.4-1.2], p < 0.0001) lost significantly more weight.

CONCLUSIONS

All socioeconomic groups experienced improvements in weight after bariatric surgery. However, as first-generation immigrants and patients residing in larger towns (>200,000 inhabitants) tend to have inferior weight loss compared to other groups, increased support in the pre- and postoperative setting for these two groups could be of value. The remaining socioeconomic factors appear to have a weaker association with postoperative weight loss.

Influence of Asian Ethnicities on Short- and Mid-term Outcomes Following Laparoscopic Sleeve Gastrectomy

PURPOSE

Prevalence of obesity in Asia has been on the increasing trend, with corresponding increase in utilisation of bariatric surgery. The objective of this study was to examine differences in weight loss outcomes following bariatric surgery between Asian ethnicities.

MATERIALS AND METHODS

A retrospective database review was conducted of patients undergoing primary laparoscopic sleeve gastrectomy between 2009 and 2013 in 14 centres from Singapore, Malaysia, Taiwan, Hong Kong, Japan, Korea, India, Australia, Switzerland, and the USA. All patients with available follow-up data at 12 months and 36 months post-surgery were included in this study. Outcome measures used were percentage excess weight loss (%EWL) and percentage total weight loss (%TWL). Differences in outcomes between ethnicities were analysed after adjusting for age, gender, baseline body mass index (BMI), and presence of diabetes.

RESULTS

The study population (n = 2150) consisted of 1122 Chinese, 187 Malays, 309 Indians, 67 Japanese, 259 Koreans, and 206 Caucasians. 67.1% were female and 32.9% were male. Mean age was 37.1 ± 11.2 years. Mean pre-operative BMI was 40.7 ± 8.1 kg/m². With the Caucasian population as reference, Japanese had the best %TWL (3.90, 95% CI 1.16-6.63, p < 0.05) and %EWL (18.55, 95% CI 10.33-26.77, p < 0.05) while the Malays had the worst outcomes. Both Chinese and Koreans had better %EWL but worse %TWL as compared to Caucasians and there were no significant differences with the Indian study group.

CONCLUSION

There are differences in weight loss outcomes following bariatric surgery between Asian ethnicities.

Impact of bariatric surgery on cancer risk reduction

Obesity is second only to tobacco as a preventable cause of cancer in the US. By multifactorial and often additive mechanisms, obesity leads to the development and promotion of 40% of the cancers diagnosed in this country, including post-menopausal breast, endometrial, colorectal, kidney, liver and pancreatic cancers, among others. Though prevention of obesity should be the ultimate goal of thoughtful and effective healthcare practices, it remains a highly prevalent condition, and morbid obesity (BMI ≥40 Kg/m²) can be refractory to lifestyle interventions in many cases. Currently bariatric surgery is an effective treatment strategy for individuals who suffer from morbid obesity or obesity with associated co-morbidities and fail to lose weight under a medically supervised diet and exercise program. The current review addresses seminal studies that have investigated the potential cancer prevention effects of bariatric surgery, demonstrating a positive impact mostly in post-menopausal breast and endometrial cancers. The controversial association between bariatric surgery and increased colorectal cancer (CRC) risk is also recognized and discussed. Finally, while bariatric surgery should not be routinely recommended as a cancer prevention strategy, it has the potential to decrease the risk for certain types of cancers as a collateral beneficial effect.

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.

Surgical Treatment of Obesity in Latinos and African Americans: Future Directions and Recommendations to Reduce Disparities in Bariatric Surgery

Introduction: Obesity and metabolic syndrome are increasingly prevalent in the United States, particularly among African Americans and Latinos. Bariatric surgery has become one of the primary treatment modalities for obesity and type 2 diabetes. However, fewer Latinos and African Americans are undergoing bariatric surgery than whites. The aim of this article is to describe the disparities in seeking and accessing bariatric surgery, describe the outcomes following bariatric procedures in Latinos and African Americans, and offer recommendations and future research directions that may assist in addressing these disparities. Methods: Original research and review articles published in English were reviewed. Results: Potential reasons why Latinos and African Americans have low rates of seeking bariatric surgery are described. Disparities in access to care and financial coverage, low rates of referral by primary care providers, and cultural attitudes toward obesity in conjunction with mistrust of the healthcare system are discussed as potential contributors to the low rate of bariatric surgery in Latinos and African Americans. Finally, disparities in bariatric surgery outcomes, comorbidities, and complications are reviewed. Conclusions: Additional research studies in bariatric surgical disparities are needed. Recommendations and future directions that may help to reduce disparities in bariatric surgery are discussed.

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.

Bariatric surgery outcomes in black patients with super morbid obesity: a 1-year postoperative review

BACKGROUND

Super morbid obesity (body mass index [BMI] > 50 kg/m²) is associated with significant comorbidities and is disparagingly prevalent among the black population. There is paucity of data regarding bariatric surgery outcomes among super morbid obese (SMO) blacks. Our aim is to evaluate the reduction in weight and resolution of comorbidities after bariatric surgery among SMO black patients at an urban academic institution.

METHODS

A retrospective review of SMO black patients who underwent bariatric surgery from August 2008 to June 2013 at Howard University Hospital. Outcomes of interest include weight loss, improvement or resolution of hypertension, type 2 diabetes, and hyperlipidemia at 12 months.

RESULTS

Eighty-seven patients met our inclusion criteria. Mean preoperative weight and BMI were 347.2 lbs and 56.8 kg/m², respectively. At 12 months, mean weight and BMI were 245.3 lbs and 40.1 kg/m², respectively. There was also significant improvement or resolution of hypertension, type 2 diabetes, and hyperlipidemia.

CONCLUSIONS

Bariatric surgery may result in significant weight loss and improvement or resolution of comorbidities in SMO black patients.

Bariatric surgery outcomes in ethnic minorities

BACKGROUND

The primary aim of this study was to examine percent excess weight loss (%EWL) across and between racial groups at 6, 12, 24, and 36 months follow-up in patients who received sleeve gastrectomy (SG) or a Roux-en-Y gastric bypass (RYGB) operation. We hypothesized that ethnic minorities (blacks and Hispanics) would have a lower %EWL than whites at 6, 12, 24, and 36 months for both SG and RYGB operations. The secondary aim was to examine %EWL within racial groups at 6, 12, 24, and 36 months as a function of the type of bariatric operation. We hypothesized that whites, blacks, and Hispanics would have a greater %EWL with RYGB than with SG.

METHODS

A total of 749 patients who underwent an SG or an RYGB operation from January 2008 to June 2014 were included. Data were collected from patients' electronic medical records. Self-reported data on race/ethnicity were also obtained from the electronic medical record and were classified into the following categories: white, Hispanic/Latino, African American or black, or other.

RESULTS

Results revealed overall differences in %EWL between blacks and whites (P < .05) and no overall differences in %EWL between Hispanics and whites (P = .697). Follow-up analyses revealed that Hispanics differed from blacks in %EWL at 6, 12, 24, and 36 months (all P < .01) and that whites differed from blacks at 6 months (P < .05). There were no significant differences between whites and Hispanics during any follow-up period. Overall, the %EWL differed by operation type (P < .01), with RYGB associated with greater %EWL than SG. When stratified by race, the only difference was found in blacks, who had a greater %EWL after RYGB compared with SG (P < .01).

CONCLUSION

Our primary hypothesis was partially supported, as blacks but not Hispanics had a lower %EWL compared to whites at 6 months. An interesting finding is that blacks had a lower %EWL than Hispanics at every time point. Moreover, our secondary hypothesis was partially supported. Results revealed that overall RYGB was related to greater %EWL compared with SG, and within racial groups, among blacks only, RYGB was associated with a greater %EWL compared with SG.

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.

Racial differences in weight loss, hemoglobin A1C, and blood lipid profiles after Roux-en-Y gastric bypass surgery

BACKGROUND

It is known that African American (AA) patients with obesity achieve less weight loss after Roux-en-Y gastric bypass surgery (RYGB) than their Caucasian (CA) counterparts. However, it is unclear how these differences in weight loss are reflected in clinical outcomes.

OBJECTIVES

To determine the effects of RYGB on hemoglobin A_1c (A_1c) and blood lipids in relationship to the variability in weight loss outcomes in a racially mixed patient population.

SETTING

University medical center.

METHODS

Retrospective analysis of clinical data from electronic medical records of CA, AA, and Hispanic American (HA) patients undergoing RYGB.

RESULTS

We used 2-way cluster analysis and identified 4 distinct weight loss×race clusters. CA patients separated into 2 clusters (45.5% and 28.2% weight loss, respectively), whereas, AA and HA patients separated into 1 cluster each (33.2% and 34.4% weight loss, respectively). Factors that significantly affected weight loss were race, age, gender, and physical activity as well as presence of hypertension and degenerative joint disease. Although all clusters had significant improvements in blood lipids, HA had an increase in total cholesterol (Total-c) and low-density lipoprotein cholesterol (LDL-c) at 2 years after surgery. All clusters had significant decreases in A_1c in the first year. At 2 years after RYGB, A_1c levels remained stable in CA and HA; however, AA had a significant increase. These racial differences in A_1c could not be explained by the smaller weight loss in AA patients.

CONCLUSION

Race is an important factor in the clinical outcomes of RYGB, especially in regard to diabetes control; however, its effect is not completely understood.

Effect of ethnicity on weight loss after bariatric surgery

BACKGROUND

Previous studies have reported better weight loss after bariatric surgery among non-Hispanic whites (NHW) versus non-Hispanic blacks (NHB) and Hispanics. The majority of these studies took place in areas where NHW are the majority. This study aimed to compare post-surgery weight outcomes by ethnicity in a geographic area where Hispanics are the majority.

METHODS

A retrospective medical chart review of 3268 patients (1561 Hispanic, 660 NHB, and 1047 NHW) who underwent Roux-en-Y gastric bypass (RYGB) or Adjustable Gastric Band (AGB) placement from 2002 to 2012 were analyzed. Percentages of excess weight loss (EWL) and body mass index (BMI) changes at 6, 12, and 24 months post-surgery were compared by ethnic group.

RESULTS

At 6 months, EWL was significantly different by ethnicity (52.7 ± 15.9 Hispanics, 49.7 ± 15.7 NHW, 43.0 ± 17.3 NHB, P < 0.001). These differences remained at 1 year (66.0 ± 20.3 Hispanics, 64.0 ± 20.3 NHW, 54.1 ± 21.3 NHB, P < 0.001) and 2 years (68.6 ± 24.1 Hispanics, 69.5 ± 21.2 NHW, 57.6 ± 25.4 NHB, P < 0.001). Ethnic group changes in BMI were similar to EWL changes. Analysis stratified by gender, type of surgery, and BMI category (<40, 40-49.99, ≥50 kg/m(2)) showed lower EWL in NHB than Hispanics and NHW. NHW had higher EWL than Hispanics only when they underwent AGB and had a BMI >40 kg/m(2).

CONCLUSIONS

Up to 2 years after RYGB, mean EWL and BMI reduction patterns are similar among NHW and Hispanics and significantly better than NHB. These patterns were comparable but not as pronounced among patients with AGB surgery. Our findings suggest that social factors may contribute to successful weight loss after bariatric surgery.

Association of race and socioeconomic status with outcomes following laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Obesity poses serious health consequences, and bariatric surgery remains the most effective and durable treatment. The goal of this study was to identify the association of race and socioeconomic characteristics with clinical outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

A retrospective review of all patients who underwent LRYGB between 2004 and 2010 was conducted. Outcomes analyzed included percent excess weight loss (%EWL), percent weight loss (%WL), change in body mass index (ΔBMI), and improvement or remission of obesity-associated medical conditions.

RESULTS

In total, 663 patients met inclusion criteria with 170 (25.6%) African Americans and 493 (74.4%) European Americans. When compared to European Americans, the African American group included significantly more women and had a significantly higher preoperative BMI and lower socioeconomic status. In adjusted analyses, African Americans had significantly lower %EWL, %WL, and ΔBMI than the European Americans at 1-, 2-, and 5-year intervals of follow-up. Adjusted spline models including all follow-up visits for all patients also demonstrated a significant difference between the races in %EWL, %WL, and ΔBMI. Both races had similar improvement or remission of type 2 diabetes mellitus, obstructive sleep apnea, hyperlipidemia, and hypertension.

CONCLUSION

Although African Americans had a statistically significant lower %EWL, %WL, and ΔBMI, both groups had durable weight loss and comparable rates of improvement or remission of obesity-associated comorbidities. Thus, both groups have significant improvement in their overall health after LRYGB.

Gender and racial/ethnic background predict weight loss after Roux-en-Y gastric bypass independent of health and lifestyle behaviors

Our study investigated how demographic, health, and behavioral factors interacted to affect weight outcomes in bariatric patients. Roux-en-Y gastric bypass (RYGB) patients who were non-Hispanic black, Hispanic, or non-Hispanic white race/ethnicity, had no revisions to their RYGB during 2004-2009, and had at least 1 year of follow-up data for body weight after surgery (n = 860) were surveyed by phone about their health and behaviors. The main outcomes of interest were percent excess weight loss and percent of initial weight lost. Participants were 47 ± 11 years old, 54 % non-Hispanic white, 25 % Hispanic, and 21 % non-Hispanic black, 82 % female, 60 % married, 82 % had some college education, and 47 % had an annual income between $35,000 and $80,000. At the time of surgery, patients had lost 50 ± 29 % of their excess weight and had achieved 24 ± 15 % initial weight lost after an average of 54 months of follow-up. After accounting for weight at the time of surgery, demographics, and self-reported health and behavior, non-Hispanic black men had significantly greater weight loss compared to non-Hispanic white men (p < .05). There were no differences between racial/ethnic groups of women in weight outcomes. Percent excess weight loss was related to greater diet soda intake, and percent initial weight lost was related to greater water intake. Independent of health status and lifestyle behaviors, age, and weight at the time of surgery, race/ethnicity, gender, and diet soda and water intake were the strongest predictors of weight outcomes after RYGB surgery.

Relative contribution of modifiable versus non-modifiable factors as predictors of racial variance in roux-en-Y gastric bypass weight loss outcomes

African-Americans have been shown to have poorer weight loss outcomes after bariatric surgery, and many reasons for such outcomes have been postulated, including metabolic and genetic differences, socioeconomic factors, and differences in culture. African-Americans have also been noted to have differences from the majority population in other psychosocial correlates to weight loss outcomes. However, the relative contribution of targetable factors in relation to non-modifiable factors to such outcomes remains unclear. African-American and Caucasian patients who had received a Roux-en-Y gastric bypass and returned for a 12-month follow up appointment (n = 415) were selected for retrospective analysis. A stepwise hierarchical regression of 12 month percent excess weight loss (% EWL) was conducted that included race after controlling for psychosocial and demographic factors previously linked to postsurgical outcomes. These variables were then compared between racial groups using independent t tests and chi-square analyses. Race remained a significant predictor of % EWL after controlling for pertinent psychosocial and demographic variables. Age and preoperative BMI were significant negative predictors, whereas presurgical BMI loss and Caucasian race were positive (p < 0.05). Percentage of follow-up appointment attendance was borderline significant. No significant racial differences were noted in these variables. Non-modifiable factors inherent to race such as metabolism play small but significant roles in the postoperative weight loss in African-American patients. Further research is needed to better elucidate the roles of targetable factors in outcomes, particularly adherence and pay status as their evaluation in this study was limited.

The Interplay Between Sex, Ethnicity, and Adipose Tissue Characteristics

The obesity epidemic in the USA affects disproportionately women and the ethnic minorities. On the other hand, female sex is traditionally associated with a favorable fat distribution preferentially in the subcutaneous depots of the lower body and with improved endocrine and metabolic function of the adipose tissue. However, these data are derived from predominantly non-Hispanic white populations. This review discusses fat distribution patterns in women of diverse ethnic backgrounds, together with data on the release of adipokines from adipose tissue in these populations. Very little information is available on how the metabolic function of the adipocyte differs depending on ethnicity. Thus, it becomes clear that future clinical and translational research should explicitly discuss and take into account the sex and ethnic background of the populations studied.

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.

Ethnicity influences weight loss 1 year after bariatric surgery: a study in Turkish, Moroccan, South Asian, African and ethnic Dutch patients

Several studies conducted in the USA have demonstrated that the effectiveness of bariatric surgery differs between patients from African and European origin. However, little is known on differences in outcomes after bariatric surgery between individuals from other ethnic backgrounds. In this retrospective study, we found that, in terms of weight loss, gastric bypass surgery is less effective in African, South Asian, Turkish and Moroccan patients than in their ethnic Dutch counterparts. Our results underscore that ethnic differences in the effectiveness of bariatric surgery are not limited to those between patients of African and European origin, but extend to other minority groups as well. Therefore, it is important that prospective studies both determine ethnic differences in weight loss-related improvement of co-morbidities and elucidate the exact reasons for these ethnic disparities.

Sex, race, and consideration of bariatric surgery among primary care patients with moderate to severe obesity

BACKGROUND

Bariatric surgery is one of few obesity treatments to produce substantial weight loss but only a small proportion of medically-eligible patients, especially men and racial minorities, undergo bariatric surgery.

OBJECTIVE

To describe primary care patients' consideration of bariatric surgery, potential variation by sex and race, and factors that underlie any variation.

DESIGN, SETTING, AND PATIENTS

Telephone interview of 337 patients with a body mass index or BMI > 35 kg/m(2) seen at four diverse primary care practices in Greater-Boston.

MEASUREMENTS

Patients' consideration of bariatric surgery.

RESULTS

Of 325 patients who had heard of bariatric surgery, 34 % had seriously considered surgery. Men were less likely than women and African Americans were less likely than Caucasian patients to have considered surgery after adjustment for sociodemographics and BMI. Comorbid conditions did not explain sex and racial differences but racial differences dissipated after adjustment for quality of life (QOL), which tended to be higher among African American than Caucasian patients. Physician recommendation of bariatric surgery was independently associated with serious consideration for surgery [OR 4.95 (95 % CI 2.81-8.70)], but did not explain variation in consideration of surgery across sex and race. However, if recommended by their doctor, men were as willing and African American and Hispanic patients were more willing to consider bariatric surgery than their respective counterparts after adjustment. Nevertheless, only 20 % of patients reported being recommended bariatric surgery by their doctor and African Americans and men were less likely to receive this recommendation; racial differences in being recommended surgery were also largely explained by differences in QOL. High perceived risk to bariatric surgery was the most commonly cited barrier; financial concerns were uncommonly cited.

LIMITATIONS

Single geographic region; examined consideration and not who eventually proceeded with bariatric surgery.

CONCLUSION

African Americans and men were less likely to have considered bariatric surgery and were less likely to have been recommended surgery by their doctors. Differences in how obesity affects QOL appear to account for some of these variations. High perceived risk rather than financial barrier was the major deterrent for patients.

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.

Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss

Background:

Following a bariatric surgery and massive weight-loss, the outcome is usually sullied by consequences on the body's contour and redundant skin.

Aims:

We aimed to record the frequency of contour irregularities and quantify patients’ satisfaction with appearance and anticipations from body contouring surgery.

Materials and Methods:

The ethical committee at King Abdulaziz University Hospital approved the study, and patients were consented. A cross-sectional study targeting the post-bariatric patients from May 2011 to April 2012 was conducted at our hospital. We used post-massive weight loss Satisfaction Questionnaire.

Results:

The total numbers of patients were 64 (51 women and 13 men), of which 57 patients (89.2%) developed sagging skin. Most patients were dissatisfied with their appearance after weight loss. The most common zones were the upper arms (50%) and abdomen (45%). Considerably more women (36.2%) than men (24%) were dissatisfied with certain body areas. The most noticeable expectation of patients from body contouring surgery was improved cosmetic appearance (65.6%) and self-confidence (64.1%). More women (70.58%) than men (46.15%) expected a better cosmetic appearance after body contouring (P = 0.003).

Conclusion:

After bariatric surgery, sagging excess skin is an unsatisfactory problem. Therefore, body contouring surgery must be included in morbid obesity management.

Roux-en-Y gastric bypass for morbid obesity: what are the preoperative predictors of weight loss?

Obesity has become an increasingly important health problem over the past 30 years. Presently around a quarter of the UK adult population are obese and this figure is set to increase further in the coming decades. The health consequences of obesity on multiple body systems have been well established as has the financial cost of the condition to both the individuals affected as well as to society as a whole. Bariatric surgery has been shown to be the only long term effective solution in terms of sustained weight loss and comorbidity resolution. The commonest bariatric procedure in the UK is the Roux-en-y gastric bypass which consistently results in the loss of 70%-80% of excess bodyweight. Results however are variable and in order to optimise resource allocation and avoid exposing patients unlikely to benefit from surgery to its inherent risks, much research has been done to try to identify those patients most likely to obtain a good result. The only factor which has been subjected to meta-analysis is that of preoperative weight loss which shows a positive association with postoperative weight loss following bypass surgery. Although the remaining data are not based on level 1 evidence those other preoperatively identifiable factors which are associated with an improved outcome include Caucasian or Hispanic ethnicity, higher educational status, non-shift-work working patterns, female gender and divorced or single marital status. Similarly increased levels of preoperative physical activity and an absence of binge eating behaviour are consistent with a favourable result whereas increased age, smoking and other socioeconomic factors have not been shown to have a significant impact. Conversely diabetes mellitus seems to have a slight negative correlation with postoperative weight loss; however, a history of sexual abuse or psychiatric illness has not been shown to have a lasting influence.

Equivalent weight loss with marked metabolic benefit observed in a matched cohort with and without type 2 diabetes 12 months following gastric bypass surgery

BACKGROUND

Bariatric surgery results in dramatic weight loss and improves metabolic syndrome and type 2 diabetes (T2DM). However, previous studies have noted that morbidly obese patients with T2DM experience less weight loss benefits than non-diabetic patients following bariatric surgery. We sought to determine longitudinal effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) on percent excess body mass index (BMI) loss (%EBMIL) and clinical metabolic syndrome parameters in patients with T2DM compared with appropriately matched cohort without T2DM.

METHODS

Retrospective cohort analysis of T2DM patients (n = 126) to non-T2DM patients (n = 126) matched on age (M = 48.1 ± 9.5), sex (81 % female), race (81 % Caucasian), and pre-surgical BMI (M = 49.3 ± 9.5). Lipids, glucose, hemoglobin A1c, blood pressure, co-morbidities of obesity, medications for co-morbidities, and T2DM medications were collected at baseline, 6 months and 12 months post-surgery. %EBMIL was collected at 1, 3, 6, 9, and 12 months post-surgery. One-way analyses of variance with effect sizes estimates were conducted to compare the two groups.

RESULTS

As expected, T2DM subjects had significantly greater pre-surgical HbA1c, blood glucose, blood pressure, and lipid parameters at baseline vs. non-T2DM (all p values of<0.05). At 1, 3, 6, 9, and 12 months after LRYRB, both groups had similar reduction in %EBMIL (p > 0.10). At 6 months, there was a significant reduction in HbA1c, blood glucose, and lipid in the T2DM cohort compared with pre-surgical levels (p < 0.0001). At 12 months, these values were not different to that of the non-T2DM subjects (p > 0.10).

CONCLUSIONS

When matched on appropriate factors associated with weight loss outcomes, severely obese patients with T2DM have similar post-LRYGB weight loss outcomes in the first 12 months following surgery compared with non-T2DM patients. Furthermore, T2DM surgical patients achieved significant improvement in metabolic syndrome components.

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.

Relation of depot-specific adipose inflammation to insulin resistance in human obesity

BACKGROUND:

A low-grade state of adipose tissue inflammation associated with obesity has been linked to mechanisms of systemic metabolic dysfunction. However, the relation of clinical phenotypes to depot-specific inflammation has not been well examined in human obesity.

OBJECTIVE:

To characterize the inflammatory status of subcutaneous and visceral fat depots, as assessed by tissue presence of macrophage crown-like structures (CLS) as a hallmark of chronic inflammation, and determine the relation of systemic insulin resistance to inflammatory abnormalities in subcutaneous and visceral fat.

METHODS:

We collected adipose tissue simultaneously from subcutaneous and visceral (omental and mesenteric) depots in 92 obese participants (age 42±11 years; BMI⩾30 kg m⁻²) during planned bariatric surgery. Using immunohistochemistry, we categorized individuals as CLS⁺ or CLS⁻ based on the presence or absence, respectively, of macrophage CLS in subcutaneous (CLS_s), omental (CLS_o) and mesenteric (CLS_m) adipose depots.

RESULTS:

The majority of participants exhibited adipose tissue inflammation manifest by the presence of CLS (CLS⁺) in both subcutaneous and intra-abdominal visceral depots. CLS status in subcutaneous fat was highly sensitive and modestly specific for inflammation of visceral fat. In multivariable models, plasma insulin and homeostatis model assessment levels were positively associated with CLS⁺ status in all depots independent of age, waist circumference, BMI and type 2 diabetes, and worsened with the increasing number of adipose regions involved.

CONCLUSIONS:

In severely obese participants, systemic insulin resistance is linked to adipose inflammation in both subcutaneous and visceral depots. The findings suggest that examination of subcutaneous regions that are more easily accessible by transcutaneous biopsy may prove useful in clinical studies designed to investigate adipose phenotypes in relation to human disease.