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Association of Race With Bariatric Surgery Outcomes

Educational Objective To identify to what extent outcomes after bariatric surgery are associated with race.
1 Credit CME
Key Points

Question  Do outcomes of bariatric surgery differ between black and white patients?

Findings  This study of 14 000 propensity-matched black and white patients undergoing bariatric surgery in Michigan demonstrated that black patients had higher overall rates of complications and health care resource utilization within 30 days of surgery. While weight loss at 1 year was slightly lower in black patients, comorbidity remission was similar between patient cohorts.

Meaning  This study suggests that short-term and long-term outcomes after bariatric surgery differ by race, and these differences should be considered when developing strategies to optimize results in patients undergoing weight-loss procedures.


Importance  The outcomes of bariatric surgery vary considerably across patients, but the association of race with these measures remains unclear.

Objective  To examine the association of race on perioperative and 1-year outcomes of bariatric surgery.

Design, Setting, and Participants  Propensity score matching was used to assemble cohorts of black and white patients from the Michigan Bariatric Surgery Collaborative who underwent a primary bariatric operation (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding) between June 2006 and January 2017. Cohorts were balanced on baseline characteristics and procedure. Conditional fixed-effects models were used to evaluate the association of race on outcomes within hospitals and surgeons. Data analysis occurred from June 2006 through August 2018.

Main Outcomes and Measures  Thirty-day complications and health care resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction.

Results  In each group, 7105 patients were included. Black patients had a higher rate of any complication (628 [8.8%] vs 481 [6.8%]; adjusted odds ratio, 1.33 [95% CI, 1.17-1.51]; P = .02), but there were no significant differences in the rates of serious complications (178 [2.5%] vs 135 [1.9%]; adjusted odds ratio, 1.32 [95% CI, 1.05-1.66]; P = .29) or mortality (5 [0.10%] vs 7 [0.10%]; adjusted odds ratio, 0.73 [95% CI, 0.23-2.31]; P = .54). Black patients had a greater length of stay (mean [SD], 2.2 [3.0] days vs 1.9 [1.7] days; adjusted odds ratio, 0.30 [95% CI, 0.20-0.40]; P < .001), as well as a higher rate of emergency department visits (541 [11.6%] vs 826 [7.6%]; adjusted odds ratio, 1.60 [95% CI, 1.43-1.79]; P < .001) and readmissions (414 [5.8%] vs 245 [3.5%]; adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P < .001). At 1 year, black patients had lower mean total body weight loss and as a percentage of weight (32.0 kg [26%]; vs 38.3 kg [29%]; P < .001) and this held true across procedures. Remission of hypertension was lower for black patients (564 [40.0%] vs 1096 [56.0%]; P < .001), but the rate of sleep apnea remission (467 [62.6%] vs 615 [56.1%]; P = .005) and gastroesophageal reflux disease (309 [78.6%] vs 453 [75.4%]; P = .049) were higher. There were no significant differences in remission of diabetes with insulin dependence, diabetes without insulin dependence,or hyperlipidemia hyperlipidemia. Fewer black patients than white patients reported a good or very good quality of life (1379 [87.2%] vs 2133 [90.4%]; P = .002) and being very satisfied with surgery (1908 [78.4%] vs 2895 [84.2%]; P < .001) at 1 year.

Conclusions and Relevance  Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients. While sleep apnea and gastroesophageal reflux disease remission were higher and hypertension remission lower in black patients, comorbidity remission was otherwise similar between matched cohorts. Racial and cultural differences among patients should be considered when designing strategies to optimize outcomes with bariatric surgery.

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Article Information

Corresponding Author: Jonathan F. Finks, MD, Department of Surgery, University of Michigan Health Systems, 1500 E Medical Center Dr, 2926 Taubman Center, Ann Arbor, MI 48109 (

Accepted for Publication: December 6, 2018.

Published Online: March 6, 2019. doi:10.1001/jamasurg.2019.0029

Correction: This article was corrected on June 5, 2019, to fix an incorrectly stated income bracket. In both Table 1 and the Results section, the income range “$45 000-$75 999” should have been written “$45 000-$75 000.” The error has been corrected.

Author Contributions: Dr Finks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wood, Carlin, Ghaferi, Birkmeyer, Finks.

Acquisition, analysis, or interpretation of data: Carlin, Varban, Hawasli, Bonham, Birkmeyer, Finks.

Drafting of the manuscript: Wood, Bonham, Birkmeyer, Finks.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Bonham, Birkmeyer, Finks.

Obtained funding: Ghaferi, Birkmeyer.

Administrative, technical, or material support: Wood, Ghaferi, Finks.

Supervision: Wood, Carlin, Ghaferi, Finks.

Conflict of Interest Disclosures: Drs Finks, Varban, and Ghaferi receive salary support from Blue Cross Blue Shield Michigan/Blue Care Network for their role in the leadership of the Michigan Bariatric Surgery Collaborative. Dr Carlin receives an honorarium from Blue Cross Blue Shield Michigan/Blue Care Network for his role as Executive Committee Chair of the Michigan Bariatric Surgery Collaborative. No other disclosures were reported.

Funding/Support: This work was funded by Blue Cross Blue Shield Michigan/ Blue Care Network.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Steinbrook  R.  Surgery for severe obesity.  N Engl J Med. 2004;350(11):1075-1079. doi:10.1056/NEJMp048029PubMedGoogle ScholarCrossref
Adams  TD, Gress  RE, Smith  SC,  et al.  Long-term mortality after gastric bypass surgery.  N Engl J Med. 2007;357(8):753-761. doi:10.1056/NEJMoa066603PubMedGoogle ScholarCrossref
Buchwald  H, Avidor  Y, Braunwald  E,  et al.  Bariatric surgery: a systematic review and meta-analysis.  JAMA. 2004;292(14):1724-1737. doi:10.1001/jama.292.14.1724PubMedGoogle ScholarCrossref
Schauer  PR, Kashyap  SR, Wolski  K,  et al.  Bariatric surgery versus intensive medical therapy in obese patients with diabetes.  N Engl J Med. 2012;366(17):1567-1576. doi:10.1056/NEJMoa1200225PubMedGoogle ScholarCrossref
Birkmeyer  NJ, Dimick  JB, Share  D,  et al; Michigan Bariatric Surgery Collaborative.  Hospital complication rates with bariatric surgery in Michigan.  JAMA. 2010;304(4):435-442. doi:10.1001/jama.2010.1034PubMedGoogle ScholarCrossref
Flum  DR, Belle  SH, King  WC,  et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.  Perioperative safety in the longitudinal assessment of bariatric surgery.  N Engl J Med. 2009;361(5):445-454. doi:10.1056/NEJMoa0901836PubMedGoogle ScholarCrossref
Nguyen  NT, Masoomi  H, Magno  CP, Nguyen  XM, Laugenour  K, Lane  J.  Trends in use of bariatric surgery, 2003-2008.  J Am Coll Surg. 2011;213(2):261-266. doi:10.1016/j.jamcollsurg.2011.04.030PubMedGoogle ScholarCrossref
Carlin  AM, Zeni  TM, English  WJ,  et al; Michigan Bariatric Surgery Collaborative.  The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity.  Ann Surg. 2013;257(5):791-797. doi:10.1097/SLA.0b013e3182879dedPubMedGoogle ScholarCrossref
Courcoulas  AP, Christian  NJ, Belle  SH,  et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.  Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity.  JAMA. 2013;310(22):2416-2425.PubMedGoogle Scholar
Still  CD, Wood  GC, Chu  X,  et al.  Clinical factors associated with weight loss outcomes after Roux-en-Y gastric bypass surgery.  Obesity (Silver Spring). 2014;22(3):888-894. doi:10.1002/oby.20529PubMedGoogle ScholarCrossref
Admiraal  WM, Celik  F, Gerdes  VE, Dallal  RM, Hoekstra  JB, Holleman  F.  Ethnic differences in weight loss and diabetes remission after bariatric surgery: a meta-analysis.  Diabetes Care. 2012;35(9):1951-1958. doi:10.2337/dc12-0260PubMedGoogle ScholarCrossref
Coleman  KJ, Huang  YC, Hendee  F, Watson  HL, Casillas  RA, Brookey  J.  Three-year weight outcomes from a bariatric surgery registry in a large integrated healthcare system.  Surg Obes Relat Dis. 2014;10(3):396-403. doi:10.1016/j.soard.2014.02.044PubMedGoogle ScholarCrossref
Harvin  G, DeLegge  M, Garrow  DA.  The impact of race on weight loss after Roux-en-Y gastric bypass surgery.  Obes Surg. 2008;18(1):39-42. doi:10.1007/s11695-007-9278-9PubMedGoogle ScholarCrossref
Lutfi  R, Torquati  A, Sekhar  N, Richards  WO.  Predictors of success after laparoscopic gastric bypass: a multivariate analysis of socioeconomic factors.  Surg Endosc. 2006;20(6):864-867. doi:10.1007/s00464-005-0115-8PubMedGoogle ScholarCrossref
Ng  J, Seip  R, Stone  A, Ruano  G, Tishler  D, Papasavas  P.  Ethnic variation in weight loss, but not co-morbidity remission, after laparoscopic gastric banding and Roux-en-Y gastric bypass.  Surg Obes Relat Dis. 2015;11(1):94-100. doi:10.1016/j.soard.2014.07.013PubMedGoogle ScholarCrossref
Elli  EF, Gonzalez-Heredia  R, Patel  N,  et al.  Bariatric surgery outcomes in ethnic minorities.  Surgery. 2016;160(3):805-812. doi:10.1016/j.surg.2016.02.023PubMedGoogle ScholarCrossref
Istfan  N, Anderson  WA, Apovian  C, Ruth  M, Carmine  B, Hess  D.  Racial differences in weight loss, hemoglobin A1C, and blood lipid profiles after Roux-en-Y gastric bypass surgery.  Surg Obes Relat Dis. 2016;12(7):1329-1336. doi:10.1016/j.soard.2015.12.028PubMedGoogle ScholarCrossref
Sudan  R, Winegar  D, Thomas  S, Morton  J.  Influence of ethnicity on the efficacy and utilization of bariatric surgery in the USA.  J Gastrointest Surg. 2014;18(1):130-136. doi:10.1007/s11605-013-2368-1PubMedGoogle ScholarCrossref
Nguyen  GC, Patel  AM.  Racial disparities in mortality in patients undergoing bariatric surgery in the U.S.A.  Obes Surg. 2013;23(10):1508-1514. doi:10.1007/s11695-013-0957-4PubMedGoogle ScholarCrossref
Weller  WE, Rosati  C, Hannan  EL.  Predictors of in-hospital postoperative complications among adults undergoing bariatric procedures in New York state, 2003.  Obes Surg. 2006;16(6):702-708. doi:10.1381/096089206777346790PubMedGoogle ScholarCrossref
Dorman  RB, Miller  CJ, Leslie  DB,  et al.  Risk for hospital readmission following bariatric surgery.  PLoS One. 2012;7(3):e32506. doi:10.1371/journal.pone.0032506PubMedGoogle ScholarCrossref
Patterson  WL, Peoples  BD, Gesten  FC.  Predicting potentially preventable hospital readmissions following bariatric surgery.  Surg Obes Relat Dis. 2015;11(4):866-872.PubMedGoogle ScholarCrossref
Girotti  ME, Shih  T, Revels  S, Dimick  JB.  Racial disparities in readmissions and site of care for major surgery.  J Am Coll Surg. 2014;218(3):423-430. doi:10.1016/j.jamcollsurg.2013.12.004PubMedGoogle ScholarCrossref
Parsons  HM, Habermann  EB, Stain  SC, Vickers  SM, Al-Refaie  WB.  What happens to racial and ethnic minorities after cancer surgery at American College of Surgeons National Surgical Quality Improvement Program hospitals?  J Am Coll Surg. 2012;214(4):539-547. doi:10.1016/j.jamcollsurg.2011.12.024PubMedGoogle ScholarCrossref
Sosa  JA, Mehta  PJ, Wang  TS, Yeo  HL, Roman  SA.  Racial disparities in clinical and economic outcomes from thyroidectomy.  Ann Surg. 2007;246(6):1083-1091. doi:10.1097/SLA.0b013e31812eecc4PubMedGoogle ScholarCrossref
Taub  DA, Hollenbeck  BK, Cooper  KL,  et al.  Racial disparities in resource utilization for cystectomy.  Urology. 2006;67(2):288-293. doi:10.1016/j.urology.2005.09.003PubMedGoogle ScholarCrossref
Tsai  TC, Orav  EJ, Joynt  KE.  Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care.  Ann Surg. 2014;259(6):1086-1090. doi:10.1097/SLA.0000000000000326PubMedGoogle ScholarCrossref
Arbaje  AI, Wolff  JL, Yu  Q, Powe  NR, Anderson  GF, Boult  C.  Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries.  Gerontologist. 2008;48(4):495-504. doi:10.1093/geront/48.4.495PubMedGoogle ScholarCrossref
Joynt  KE, Jha  AK.  A path forward on Medicare readmissions.  N Engl J Med. 2013;368(13):1175-1177. doi:10.1056/NEJMp1300122PubMedGoogle ScholarCrossref
Shi  L, Lebrun-Harris  LA, Daly  CA,  et al.  Reducing disparities in access to primary care and patient satisfaction with care: the role of health centers.  J Health Care Poor Underserved. 2013;24(1):56-66. doi:10.1353/hpu.2013.0022PubMedGoogle ScholarCrossref
Mechlin  MB, Maixner  W, Light  KC, Fisher  JM, Girdler  SS.  African Americans show alterations in endogenous pain regulatory mechanisms and reduced pain tolerance to experimental pain procedures.  Psychosom Med. 2005;67(6):948-956. doi:10.1097/01.psy.0000188466.14546.68PubMedGoogle ScholarCrossref
Rahim-Williams  FB, Riley  JL  III, Herrera  D, Campbell  CM, Hastie  BA, Fillingim  RB.  Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics.  Pain. 2007;129(1-2):177-184. doi:10.1016/j.pain.2006.12.016PubMedGoogle ScholarCrossref
White-Means  SI, Osmani  AR.  Racial and ethnic disparities in patient-provider communication with breast cancer patients: evidence from 2011 MEPS and experiences with cancer supplement.  Inquiry. 2017;54:46958017727104.PubMedGoogle Scholar
Wong  MS, Gudzune  KA, Bleich  SN.  Provider communication quality: influence of patients’ weight and race.  Patient Educ Couns. 2015;98(4):492-498. doi:10.1016/j.pec.2014.12.007PubMedGoogle ScholarCrossref
Bayham  BE, Bellanger  DE, Hargroder  AG, Johnson  WD, Greenway  FL.  Racial differences in weight loss, payment method, and complications following Roux-en-Y gastric bypass and sleeve gastrectomy.  Adv Ther. 2012;29(11):970-978. doi:10.1007/s12325-012-0062-4PubMedGoogle ScholarCrossref
Limbach  KE, Ashton  K, Merrell  J, Heinberg  LJ.  Relative contribution of modifiable versus non-modifiable factors as predictors of racial variance in roux-en-Y gastric bypass weight loss outcomes.  Obes Surg. 2014;24(8):1379-1385. doi:10.1007/s11695-014-1213-2PubMedGoogle ScholarCrossref
Sugerman  HJ, Wolfe  LG, Sica  DA, Clore  JN.  Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss.  Ann Surg. 2003;237(6):751-756. doi:10.1097/01.SLA.0000071560.76194.11PubMedGoogle Scholar
Bacha  F, Arslanian  SA.  Ghrelin and peptide YY in youth: are there race-related differences?  J Clin Endocrinol Metab. 2006;91(8):3117-3122. doi:10.1210/jc.2005-2448PubMedGoogle ScholarCrossref
Brownley  KA, Heymen  S, Hinderliter  AL, Galanko  J, Macintosh  B.  Low-glycemic load decreases postprandial insulin and glucose and increases postprandial ghrelin in white but not black women.  J Nutr. 2012;142(7):1240-1245. doi:10.3945/jn.111.146365PubMedGoogle ScholarCrossref
Velásquez-Mieyer  PA, Cowan  PA, Pérez-Faustinelli  S,  et al.  Racial disparity in glucagon-like peptide 1 and inflammation markers among severely obese adolescents.  Diabetes Care. 2008;31(4):770-775. doi:10.2337/dc07-1525PubMedGoogle ScholarCrossref
Foster  GD, Wadden  TA, Swain  RM, Anderson  DA, Vogt  RA.  Changes in resting energy expenditure after weight loss in obese African American and white women.  Am J Clin Nutr. 1999;69(1):13-17. doi:10.1093/ajcn/69.1.13PubMedGoogle ScholarCrossref
Staiano  AE, Harrington  DM, Johannsen  NM,  et al.  Uncovering physiological mechanisms for health disparities in type 2 diabetes.  Ethn Dis. 2015;25(1):31-37.PubMedGoogle Scholar
Weinsier  RL, Hunter  GR, Schutz  Y, Zuckerman  PA, Darnell  BE.  Physical activity in free-living, overweight white and black women: divergent responses by race to diet-induced weight loss.  Am J Clin Nutr. 2002;76(4):736-742. doi:10.1093/ajcn/76.4.736PubMedGoogle ScholarCrossref
Baker  EA, Schootman  M, Barnidge  E, Kelly  C.  The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines.  Prev Chronic Dis. 2006;3(3):A76.PubMedGoogle Scholar
Morland  K, Wing  S, Diez Roux  A, Poole  C.  Neighborhood characteristics associated with the location of food stores and food service places.  Am J Prev Med. 2002;22(1):23-29. doi:10.1016/S0749-3797(01)00403-2PubMedGoogle ScholarCrossref
Swinburn  B, Egger  G, Raza  F.  Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity.  Prev Med. 1999;29(6, pt 1):563-570. doi:10.1006/pmed.1999.0585PubMedGoogle ScholarCrossref
White  MA, O’Neil  PM, Kolotkin  RL, Byrne  TK.  Gender, race, and obesity-related quality of life at extreme levels of obesity.  Obes Res. 2004;12(6):949-955. doi:10.1038/oby.2004.116PubMedGoogle ScholarCrossref
Becker  DM, Yanek  LR, Koffman  DM, Bronner  YC.  Body image preferences among urban African Americans and whites from low income communities.  Ethn Dis. 1999;9(3):377-386.PubMedGoogle Scholar
Greenberg  DR, LaPorte  DJ.  Racial differences in body type preferences of men for women.  Int J Eat Disord. 1996;19(3):275-278. doi:10.1002/(SICI)1098-108X(199604)19:3<275::AID-EAT6>3.0.CO;2-JPubMedGoogle ScholarCrossref
Powell  AD, Kahn  AS.  Racial differences in women’s desires to be thin.  Int J Eat Disord. 1995;17(2):191-195. doi:10.1002/1098-108X(199503)17:2<191::AID-EAT2260170213>3.0.CO;2-ZPubMedGoogle ScholarCrossref
Allan  JD, Mayo  K, Michel  Y.  Body size values of white and black women.  Res Nurs Health. 1993;16(5):323-333. doi:10.1002/nur.4770160503PubMedGoogle ScholarCrossref
Stevens  J, Kumanyika  SK, Keil  JE.  Attitudes toward body size and dieting: differences between elderly black and white women.  Am J Public Health. 1994;84(8):1322-1325. doi:10.2105/AJPH.84.8.1322PubMedGoogle ScholarCrossref
Lynch  CS, Chang  JC, Ford  AF, Ibrahim  SA.  Obese African-American women’s perspectives on weight loss and bariatric surgery.  J Gen Intern Med. 2007;22(7):908-914. doi:10.1007/s11606-007-0218-0PubMedGoogle ScholarCrossref
Minor  DS, Wofford  MR, Jones  DW.  Racial and ethnic differences in hypertension.  Curr Atheroscler Rep. 2008;10(2):121-127. doi:10.1007/s11883-008-0018-yPubMedGoogle ScholarCrossref
Cooper  LA, Roter  DL, Johnson  RL, Ford  DE, Steinwachs  DM, Powe  NR.  Patient-centered communication, ratings of care, and concordance of patient and physician race.  Ann Intern Med. 2003;139(11):907-915. doi:10.7326/0003-4819-139-11-200312020-00009PubMedGoogle ScholarCrossref
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