While weight loss surgery offers one of the best opportunities to improve health and reduce obesity related illnesses, the nearly 100,000 Americans who undergo bariatric surgery each year represent only a small fraction of people who are medically eligible for the procedure. Among those who have surgery, Caucasian Americans are twice as likely as African Americans to have weight loss surgery. On the surface, the data appear to signal racial disparity, but when researchers at Beth Israel Deaconess Medical Center dug deeper to ask why this variation exists, the answer was more complicated.
BIDMC investigators interviewed 337 moderately to severely obese patients from four diverse primary care practices in the Greater Boston area. Each patient reported a body mass index of 35 or higher, the baseline requirement to be considered medically eligible for bariatric surgery. The results were published in January in the Journal of General Internal Medicine.
"It's been assumed that the racial barrier to weight loss surgery is economic, that people don't have insurance, are underinsured or can't afford the copay or the time off work and that's why we don't see certain groups seeking treatment," says lead author Christina Wee, MD, MPH, Associate Section Chief for Research in the Division of General Medicine and Primary. "But, in fact the patients we talked to rarely mentioned economic barriers, so that didn't account for two-fold difference between Caucasian and African Americans."
Wee also looked at level of education and impact of comorbidities like high blood pressure and type 2-diabetes. Neither accounted for the differences across race. But when she factored in reported quality of life using an obesity specific quality of life index that captures physical function, sexual function, work life, self-esteem and social stigma, the differences between races disappeared.
"What we found is that a significant reason that more African Americans have not considered weight loss surgery is that obesity has not diminished their quality of life as much as it has diminished quality of life for Caucasians," says Wee.
Additionally, Wee found that just as many African American patients as Caucasian patients said they would consider weight loss surgery if their doctor recommended it, but doctors were less likely to recommend surgery for African Americans than for Caucasians.
"This is also likely related to quality of life," says Wee. She found that differences in doctor recommendations were reduced after accounting for difference in patient reported quality of life. Wee says that if patients aren't bringing up concerns on their own, doctors may not be talking with them about issues related to diminished sexual function or lower self-esteem.
"Quality of life is clearly a very important motivator to patients with obesity. And what this study shows is that those quality of life differences across race are so important that they may actually drive decision making in a way that creates racial differences in how people think about undergoing treatment," says Wee." It speaks to the importance of thinking about the whole patient, factoring in personal values and facilitating individualized decision making."
Wee and colleagues from Boston Medical Center previously reported on the importance of "whole patient" considerations in doctor and patient discussions about type of weight loss surgery in a December 2013 article published in the Journal of the American College of Surgeon.
Additionally, Wee says it's important for doctors to be knowledgeable about the risks associated with weight loss surgery and to talk with their patients about it. "Bariatric surgery is a serious procedure with real risks and complications, but the fact that risk was identified as the number one barrier to surgery may suggest that patients often have a preconceived notion of just how risky it is and we don't know if those perceptions are accurate unless we talk about it."
The study also found that women were several times more likely to consider undergoing bariatric surgery than men, and that doctors were less likely to recommend weight loss surgery to men than women. Wee expected to account for this gender variation by factoring in quality of life measures, but it did not. Women did have higher weight loss goals than men and this in part accounted for some of the gender difference in having considered weight loss surgery.