Bariatric Times

MAR 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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The Medical Student Notebook 9 Bariatric Times • March 2018 SOCIOECONOMIC FACTORS Breaking the issue of access into smaller pieces, multiple studies have looked at the socioeconomic factors that make patients more likely to be candidates for bariatric surgery, but less likely to obtain bariatric surgery. First, it is important to examine the socioeconomic factors that make people more likely to have obesity in the US. A study published in 2010 found that a total of 22 million people were identified as eligible for bariatric surgery in the US, using the National Institute of Health (NIH) criteria. The group eligible for bariatric surgery had significantly lower family income, lower education levels, less access to healthcare, and a greater proportion of racial minorities, compared to the general population. The bariatric eligible group also had significant adverse economic and health-related markers, including greater days of work lost. More than one-third of bariatric eligible patients were either uninsured or underinsured, and 15 percent had incomes less than the poverty level. 4 This study, and many others, have repeatedly proven that economic factors are indisputably related to who becomes obese in the US. The 2010 study also showed, in direct contradiction to the economic characteristics of the bariatric eligible population, that most bariatric procedures were performed in patients who had private insurance, were white, and had greater median incomes. Significant disparities associated with a decreased likelihood of undergoing bariatric surgery included race, income, insurance type, and sex. 4 Therefore, while obesity is predicted by low income, lack of insurance, and adverse economic markers, including days of work lost, a patient is more likely to get a bariatric procedure if they have a greater income, private insurance, and are white. Looking specifically at private versus public insurance, a recently published study found that, as a group, Medicare and Medicaid patients experience higher rates of obesity and related complications and are most in need of bariatric surgery. But, in more than 100,000 cases of bariatric surgery examined, the majority of patients had private insurance; Medicare and Medicaid patients accounted for a low percentage of cases (less than 15% total). 5 The researchers also found that the Medicare and Medicaid patients had an increased risk of complications compared to privately insured patients. 5 Again, need does not correspond with economic access. BARIATRIC CARE OUTSIDE THE US Of interest, a study in Canada, where all patients have public insurance, examined who is surgery- eligible versus who actually receives bariatric surgery. The conclusions were surprisingly similar to the results in the US. The study found that patients receiving surgery were predominantly of higher socioeconomic status (SES), which was difficult to explain given Canada's universal healthcare system. 6 Instead, perhaps this points to the reality that individuals with higher SES status are more easily able to take time off from work to get surgery or more able to afford the additional child care and other expenses that come from taking time to recover from surgery. In addition, the necessary post-surgical diet changes require access to healthy food, including readily available fruits and vegetables. Fresh food is not always as accessible in poorer communities, where food deserts can be pervasive, and healthy foods can be expensive. In addition, the Canadian study showed that women were four times more likely to undergo surgery compared to men. This pattern was not completely explained by the two- fold higher prevalence of obesity in women. However, as the researchers accurately pointed out, "Women may be more likely to seek surgery for body image reasons, and it is also possible that sex-related differences in the perceived mental and physical health impact of severe obesity may explain the higher tendency for women to seek surgery." 6 The study also found that obesity-related comorbidities were less common in bariatric surgery recipients compared to those eligible for surgery. The researchers concluded that this might be due to candidate selection bias, where surgeons or programs select patients

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