October 2017 Issue

Cultural Disparities in Obesity, Bariatric Surgery
By Paul Davidson, PhD
Today's Dietitian
Vol. 19, No. 10, P. 42

Learn more about the prevalence of obesity among different ethnic groups, the factors affecting the provision of weight loss surgery, and the cultural issues that impact health outcomes.

It will come as no surprise to most dietitians that few issues threaten the general health of Americans today more than the epidemic of overweight and obesity. Despite repeated efforts to rein in appetites and increase involvement in physical activity on the part of the government, dietitians, exercise physiologists, gyms, and commercial weight loss programs, the weight trends have been trailing upwards for many years.

At this point, more than two-thirds of adult Americans are at least overweight, while nearly 38% are obese. Women have higher rates of obesity at 40.4% relative to men, for which 35% fit the criteria. However, more men are overweight at 72%, whereas 64% of women are overweight. In terms of age, the largest percentage of those with obesity are middle aged, between the ages of 40 and 59, followed by adults over age 60; those under age 40 have somewhat lower rates. While overall childhood obesity rates have tripled since 1980 and doubled over the past decade, the rate has been leveling off at around 17% for the past seven years.1 Unfortunately, the global picture regarding excess weight has seen a seismic shift. A recent study of international weight trends found that, in 1975, 3.2% of males and 6.4% of females were obese. By 2014, this number had more than tripled to 10.8% for men and had risen to 14.9% for women. As a result, for the first time in human history, there are more individuals who are obese than are underweight. It's now anticipated that if current trends remain unchecked, these numbers will grow to 18% in men and 21% in women worldwide.2 Clearly, despite nutrition professionals' best efforts, weight gain worldwide remains a daunting challenge and a good reason to believe there's job security within the field.

Such numbers in and of themselves are scary in general, but it's essential to mention that overweight and obesity disproportionately impacts individuals from specific ethnic minority groups. In 2015, overweight and obesity rates among ethnic groups were as follows: blacks (72.7%), Native Americans/Alaska Natives (68.6%), Hispanics (70%), whites (63.2%), and Asian/Pacific Islanders (37.7%).3 Among children aged 2 to 19, 38.9% of Hispanics, 35.2% of blacks, 28.5% of whites, and 19.5% of Asians are overweight or obese.4 Based on geography, obesity is most common in the Southeast and Midwest and is significantly higher in urban rather than rural areas. In nearly all states, obesity rates are higher among Hispanic adults relative to non-Hispanic white adults, and obesity rates for non-Hispanic black adults are the highest in the nation.5 Therefore, it's important to recognize that in treating obesity, the largest percentage of individuals suffering with the condition comes from a minority culture.

Treatment Modalities
In examining the medical treatment of overweight and obesity, experts have concluded that, at best, evidence suggests most individuals achieve a 5% to 10% reduction in weight within a multidisciplinary weight loss program that may involve primary care physicians, nurses, dietitians, mental health specialists, and exercise physiologists.6 It has been demonstrated that programs that highlight the value of decreased caloric intake and more exercise along with behavioral treatment lead to greater weight loss than programs that omit one of these critical components. Research also supports the finding that more sessions are linked to greater reductions in weight.7 Individuals also are often referred to programs within their community, which may encompass commercial weight loss systems, such as Weight Watchers, Nutrisystem, and Medi-Weightloss, or 12-step programs including Overeaters Anonymous or Food Addicts in Recovery Anonymous. When BMI rises above 27 kg/m2 with the presence of a comorbid condition, or is greater than or equal to 30 kg/m2 without a comorbidity, pharmacotherapy is recommended as a useful adjunct to diet, exercise, and behavior modification. There are several medications indicated for weight loss, including phentermine, topiramate/phentermine, lorcaserin, orlistat, naltrexone/bupropion, and liraglutide. Each option has advantages and disadvantages, including cost, side effects, and effectiveness profiles.8

However, once an individual's BMI rises above 35 kg/m2 in the presence of a specific comorbid condition, or is above 40 kg/m2 without a comorbid condition, bariatric surgery should be considered as a viable treatment option. Metabolic and bariatric surgery has been shown empirically to be the most effective, durable treatment for obesity despite having a utilization rate of only 1% among eligible candidates. With such low penetration, the vast majority of individuals struggling with obesity will continue to rely on dietitians, primary care doctors, personal trainers, and others focused on weight loss, and thus today's dietitian needs to be informed regarding all treatment options for this condition. Of course, a specialization within dietetics is that of the bariatric dietitian, who provides the counseling and nutrition advice that helps bariatric surgery patients succeed long term. With this treatment option, the surgery is only the first major step in a lifelong pursuit of nutritional and behavior change. In gaining familiarity with bariatrics, the most popular surgical procedure in the nation is the laparoscopic sleeve gastrectomy, in which approximately 75% to 80% of the stomach is removed. Typically, it leads to 50% to 60% excess weight loss within 18 months. The Roux-en-Y gastric bypass (RYGB), involving making the usable stomach the size of an egg and rerouting the intestine to bypass the duodenum, leads to 60% to 70% excess weight loss over the same time frame. The laparoscopic adjustable gastric band procedure, in which an inflatable silicone band is placed around the top of the stomach, creates a small pouch that leads to 40% to 50% of excess weight loss in a year and a half, though the lack of durability of those results has made this a much less popular procedure.9

Disparity in Bariatric Surgery
The number of bariatric surgery procedures in the United States has risen dramatically within the past 20 years, with fewer than 30,000 procedures done at the time, peaking to more than 220,000 surgeries in a year in 2008 and 2009, and then retreating to 196,000 procedures by 2015. These data are tracked by the American Society for Metabolic and Bariatric Surgery and are publicly available on its website. Of those procedures, 53.8% were for the sleeve, 23% were for the gastric bypass, 5.7% were for the band, 13.6% of surgeries were revisions of previous surgeries, and miscellaneous surgical types made up the rest.10 The first worldwide data for the number of bariatric surgeries performed were published in 1997, at which time 36,700 procedures took place. The majority of those were in the United States, Western Europe, and Australia.11 By 2013, bariatric procedures worldwide had soared to nearly 0.5 million. Most notable has been a rapid increase outside continents where such surgeries were originally popularized. South America now rivals North America in terms of numbers of procedures. In Asia, surgeries have increased 95-fold, largely due to an acknowledgment that metabolic issues arise at a lower BMI for Asians and that bariatric surgery provides the most effective means of combating such diseases, including diabetes. These latest data reveal that roughly one-half of all bariatric surgeries now involve patients of an ethnicity other than non-Hispanic white, and trends point to an even more diverse patient population in the future.12

Given the fact that those most affected by obesity in the United States are members of minority ethnic groups, one would expect the demographics of bariatric procedures to reflect those proportions. However, the reality of weight loss surgery numbers suggests that blacks and Hispanics constitute less than 10% of all bariatric surgery patients.13 By exploring Nationwide Inpatient Sample data for nearly 160,000 obese patients, Wallace and colleagues examined numerous factors associated with potential bias in the field. Their study revealed that the odds of obtaining bariatric surgery varied widely depending on specific demographic factors. Urban dwellers were four times more likely to have metabolic surgery than those living in rural environs. Females were four times more likely to get surgery than men. Those who were aged 40 to 59 were 1.5 times more likely to have surgery than those aged 20 to 39 and were six times more likely than someone over the age of 60. Anyone with private insurance had eight times the likelihood of receiving a procedure. Whites were twice as likely as blacks, Asians, or Native Americans to become a bariatric patient, whereas Hispanics were 20% less likely to receive surgery. All results were highly statistically significant, and the clinical ramifications were undeniable.14

Another study of Nationwide Inpatient Sample data revealed that while the greatest concentration of obesity can be found in the South, individuals in that region were only one-half as likely to receive bariatric surgery as someone living in the Northeast. This ratio also was true for someone living in the Midwest, who also was one-half as likely to have a bariatric procedure performed than someone from the Northeast.15 Commentary on this study pointed to the markedly different levels of insurance coverage offered for the procedures by geographic region. Though seven of 10 states in the Northeast covered bariatric surgery, only three of the 15 Southern states had bariatric surgery as a covered benefit during the time of the study.16

Analysis of a decade of hospital discharges demonstrated that black women were eligible for bariatric procedures at twice the rate of white women, though they had surgery at just over one-half the rate of whites. Black men were 50% more likely to be eligible for bariatric surgeries, but had them at one-half the frequency of their white counterparts. Significant differences also were noted in blacks having lower levels of private insurance than whites.17 Another recent study found that women were more likely to receive bariatric surgery than men, and whites were more likely to have surgery than blacks. Further examination found that men, blacks, and Hispanics were more inclined to seek surgery if referred by a primary care provider. The irony, though, was that men and blacks were less likely to receive such a referral from their doctors. In all groups, perceived risks of surgery were noted to be a major deterrent to seeking the procedures. Though economics were presumed to be a significant factor in the differences, the authors found 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 lead author Christina Wee, MD, MPH.18

Disparity in Outcomes
In addition to bariatric surgeries being performed less frequently within minority populations in the United States, there seems to be disparity in outcomes. Relative to blacks, both whites and Hispanics tend to lose more weight following surgery despite blacks typically starting at a higher BMI.19 One bypass study found that at two years following RYGB surgery, white women lost more weight than black women.20 Kaiser-Permanente evaluated the results of 4,088 surgeries, one-half of which were completed on nonwhite patients. Researchers found less resolution of metabolic syndrome in general in Hispanics and non-Hispanic blacks. More specifically, resolution was greater for females, non-Hispanic whites, and college graduates who had gastric bypass. For those who were male, were older, had a higher BMI at surgery, and were nonwhite, the results were significantly poorer.21 A cohort of 37,765 RYGB patients showed that females had decreased morbidity and mortality, fewer ICU stays, shorter lengths of stay postoperatively, incurred fewer costs, and had less illness severity compared with males. Blacks had more 30-day hospital readmissions, longer lengths of stay, and more costly treatment than whites. Hispanics had fewer ICU admits and lower hospital charges than whites. With men, increased age was associated with more complications. More adverse events following surgery were seen in patients who were black and had greater illness severity.22

In trying to understand the disparity in outcomes, one study targeted a Hispanic population undergoing RYGB surgery using a comprehensive approach involving biweekly nutrition and lifestyle education group attendance for six weeks with added dietitian contact and printed informational materials. After one year, those in the comprehensive group lost 16% more excess weight, stayed more involved in exercise, and did better with protein intake than the control group.23 Another element that might contribute to surgical results could be the individual's expectations. Although not highly scientific, onlinedoctor.superdrug.com investigated the notion of beauty across the world and engaged mainly female clothing designers to retouch an original photo using Photoshop to fit their cultural ideal.

Calling the project "Perceptions of Perfection," it made headlines worldwide when published a few summers ago, as it pointed to dramatically different interpretations of what beauty looked like in different cultures. The ideal BMI range went from a low of 17 for someone from China to 25.5 for an individual from Spain. Thus, levels of motivation for a certain body type may vary dramatically based on ethnicity and cultural background, which may influence weight loss goals.24 Qualitative analysis of ethnic beliefs, at least among black women, have shown that despite higher obesity rates, black women show greater acceptance of being bigger, feeling attractive despite displeasure with their weight, a strong cultural pull towards certain foods, and less social pressure for thinness.

Another cultural issue proved to be a reluctance to focus on the self and instead to be more attentive to others within the family, part of a collectivist orientation towards the extended family rather than the individual.25 When focus groups were held in another study to look at black women's perceptions of bariatric surgery, they found that there were numerous fears about complications, weight regain, a positive identification with being somewhat larger, decreased trust in doctors, and a sense of surgery as a drastic, last-ditch option.26

Culturally Sensitive Approach to Obesity Treatment
In seeking to redress the disparities found in bariatric surgery from a cultural perspective, there's much that can be done. First, on a programmatic level, it's important to provide outreach to ethnic minority populations, particularly as they comprise the largest percentage of obese individuals. This may include offering information sessions in different languages or accompanied by a translator, meetings with primary care providers in minority neighborhoods, providing information sessions out in the community itself where individuals are more likely to attend, and educating medical professionals about the bariatric surgical benefits for all patients with obesity, including minority clients. Providing targeted education with added nutrition support in one's native language appears to make a difference in outcomes. Helping individuals who are considering surgery to negotiate insurance issues also may be paramount, particularly when English isn't their primary language.

Though only a small percentage of dietitians works within a bariatric program, most RDs will treat patients with obesity at some point in their careers on either an inpatient or outpatient basis. Some of those individuals may well have had bariatric surgery or may be considering having surgery in the future. The diversity issues the bariatric patient encounters are instructive in applying these cultural concepts to all individuals who see dietitians and health care professionals. In treating each patient, it's important to use a culturally competent approach to ensure improved communication and understanding. This includes using a native language whenever possible, encouraging familial involvement, and respecting cultural food challenges.

In culturally competent treatment, it's essential to have an awareness of one's own biases and to be able to separate individual and group differences. It's most useful to be aware of cultural views of authority figures, varied gender roles based on ethnicity, and the benefits of involving family members or personal support figures. Particularly when treating someone from a minority background, an appreciation of the social, economic, and environmental factors they face is essential.

Providing as much written material in a native language also is a huge plus. Being mindful of technical terminology and clarifying terms with specific cultural meanings also shows sensitivity. Trying to integrate dietary recommendations into one's preferred cultural food palate may go a long way to increasing the likelihood someone will be able to follow nutrition recommendations and expectations. This also includes respecting the centrality of religious food customs, such as eating a kosher diet in Judaism, following halal in Islam, avoiding beef in Hinduism, and working with fasting holidays such as Yom Kippur, Shivaratri, and Ramadan.

It's also important to recognize that weight loss goals may vary due to cultural perspectives, and these expectations should be discussed before surgery to ensure the patient's goals and those of the bariatric team are aligned. Greater efforts on the part of the individual clinician and multidisciplinary teams to both seek and make the minority patient feel welcomed, respected, and understood throughout the treatment process will be an important step in creating equity in the field of obesity surgery and the broader treatment of obesity in general.

— Paul Davidson, PhD, is a clinical psychologist specializing in behavioral health and bariatric surgery. He's the director of behavioral services at Brigham and Women's Hospital in Boston and is an instructor in psychiatry at Harvard Medical School. He's passionate about his work and the pursuit of greater wellness for all his patients.


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