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Racial disparities

Access: no racial disparities in bariatric surgery

Quality of life is why African Americans do not consider bariatric surgery
Doctors were less likely to recommend surgery for African Americans than for Caucasians

The quality of life factors, not racial disparities, are the key influences in why Caucasian Americans are twice as likely as African Americans to have bariatric surgery, according to research published 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 co-pay or the time off work and that's why we don't see certain groups seeking treatment,” said lead author Dr Christina Wee, Associate Section Chief for Research in the Division of General Medicine and Primary, from Beth Israel Deaconess Medical Center. “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.”

The 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, the baseline requirement to be considered medically eligible for bariatric surgery.

"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," she said.

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 socio-demographics and BMI.

Wee also looked at level of education and impact of comorbidities like high blood pressure and type 2-diabetes, but neither accounted for the differences across race.

The results also showed that:

  • 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
  • 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
  • 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.

However, 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.

She also 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," said Wee. "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. It speaks to the importance of thinking about the whole patient, factoring in personal values and facilitating individualised decision making."

She found that differences in doctor recommendations were reduced after accounting for difference in patient reported quality of life. She added that if patients are not bringing up concerns on their own, doctors may not be talking with them about issues related to diminished sexual function or lower self-esteem.

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