BTK Disparities Recording
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Speaker: [00:00:00] Hi, everyone. Welcome back to the bariatric surgery team on the Behind the Knife specialty series. We are welcomed by the incredible panel of bariatric surgeons.

Speaker 2: Hi, this is Matt Martin, bariatric surgeon at University of Southern California.

Speaker 3: I'm Adrian Day, medical director of the Bariatric Care Center and program director for the advanced GIMIS Forgotten Bariatric Surgery Fellowship at a place called Summa Health, Northeast Ohio Medical University in Akron, Ohio.

Speaker 4: And hey, I'm Crystal Johnson Mann. I am a bariatric surgeon at the University of Florida, where I'm also our interim medical director for bariatric and metabolic surgery.

Speaker: And I am Katie Cerrone. I'm one of the general surgery residents at the University of Southern California. Now, we have a really important topic to talk about today, something that's honestly pretty central to the field of bariatric surgery, and a topic a couple of our bariatric attending moderators have contributed to, which is disparities in access to care.

So to kick things off, we're starting with a paper from our very own Dr. [00:01:00] Matt Martin, looking at national data to understand who actually gets bariatric surgery, and maybe more importantly, who doesn't.

Speaker 2: Okay. Well, this first paper is an oldie, but hopefully a goodie. This was published back in two thousand and ten, and at the time was one of the first studies to really take a nationwide look at some of the disparities in access to bariatric surgery.

And the way we structured it was really looking at this in three phases. So first, we looked at who is actually eligible for bariatric surgery from a medical and weight standpoint. Then second, we looked at who underwent surgery during that same time period. And then third, we compared those two groups, which is really where the story comes together.

Speaker 4: I found that the scale of this study is pretty massive. You know, you guys used data from the National Health and Nutrition Examination Survey, but it estimated that over twenty-two million people in the US met criteria for bariatric surgery at that time, sort [00:02:00] of classic nineteen ninety-one consensus criteria, so a BMI of greater than or equal to forty, or a BMI of greater than or equal to thirty-five with associated comorbidities.

But then there's this other, you know, much larger group, about a hundred and fifty million people, who did not meet criteria, so those with a BMI between eighteen and a half to thirty-five, or a BMI between thirty-five and thirty-nine without a qualifying comorbidity. So this was a comparison cohort. I think one thing to note here is that all of this is based on cross-sectional data, so they couldn't really separate whether someone had already had bariatric surgery in the past.

Speaker 3: Right, Crystal. And when you look at that eligible population, it's actually not what many people might expect. Patients who met criteria for bariatric surgery were more likely to be female, more likely to be from a racial and ethnic minority, had lower income, lower education levels, and were more likely to be underinsured or frankly completely uninsured.

So already- The population with the highest need is also [00:03:00] the population facing the most socioeconomic challenges.

Speaker: Right. And then with the next phase, they looked at who actually underwent surgery. Using data from the nationwide inpatient sample, the picture looks completely different. The authors identified about eighty-seven thousand patients who had bariatric surgery.

These are mostly Caucasian women with private insurance. And one statistic that really stood out to me is that less than one percent of surgeries performed were on uninsured patients.

Speaker 2: Yeah, and that's, that's a, a number to keep in mind because I don't think we've seen significant improvement in that from two thousand and ten.

That's where phase three of this study really highlighted some of the disparities, because if you look at those patients that were eligible for bariatric surgery versus those who actually received surgery, only about zero point four percent of eligible patients underwent bariatric surgery in two thousand and six.

Uh, and that's another number that I think [00:04:00] continues to pop up of less than one percent of eligible patients, uh, actually get bariatric surgery. Patients who did get surgery in our analysis were disproportionately those who had higher socioeconomic status, especially those with better insurance, which tended to be private insurance.

Speaker 3: Yeah, you know, Matt, striking mismatches, likely multifactorial. You know, you have insurance barriers, differences in referral patterns, access to specialized bariatric centers, and then there's the broader systemic inequities. And there's also the piece that's harder to measure, the intangibles, the differences in how obesity and bariatric surgery are perceived across different communities, by different practitioners, by patients, all of which can influence whether patients even seek care in the first place.

You know, I always like to say that bias, stigma, and prejudice, those things together, they stop access to care before it even begins.

Speaker 4: [00:05:00] I mean, we could go on a whole episode on just that one piece right there, but we don't have time. But I completely agree with you, Adrian. Um, there are so many factors that really come into play.

And just to take a step back and we're, you know, to consider things, this study in particular does use two very large national datasets. It names a nationwide inpatient sample, so it gives a really broad snapshot of the overall US population, and it's still retrospective, so we can't say that those factors cause the disparities, just that they're strongly associated.

Speaker 2: And that being said, this paper really did lay the groundwork for understanding, uh, the problem at hand. And I think one of the most striking numbers is that there were about three and a half million people who were eligible for surgery based on medical criteria, but uninsured or underinsured, and they had essentially no representation in the surgical population So obviously, insurance alone seems to be a massive barrier to receiving bariatric surgical care.

Speaker: [00:06:00] Right. And it's important to recognize that this data is now 20 years old. The CDC reports that 15 years ago, the uninsured rate was about 16% compared to 7% in 2023. But I think it would be interesting to repeat this study and see if the insurance barrier has improved at all, especially with some of our governmental programs that have hopefully improved health insurance if we're seeing the same patterns today.

Speaker 3: And even though insurance may not drive why patients want surgery, it may determine whether they even have a chance to consider it, not to mention the long approval process that some insurance companies lay in front of the patients and the providers who try to provide these operations for them. And it's also important to note that this is not limited to bariatric surgery, but today also to obesity management medications, a topic that we reviewed on this very podcast not too long ago.

Speaker: And then building on this last paper where we talked about who actually gets [00:07:00] bariatric surgery, this next study zooms in on something even earlier in the process, who even gets referred in the first place. This is a paper by our very own Dr. Crystal Johnson Mann and her team, published in 2019, looking specifically at disparities in bariatric surgery referrals.

Speaker 4: This was done when I was a fellow. This is sort of when I got the, the idea for this project. It, it's a really important perspective because, as we know, before the patient ever gets to the OR or even to our bariatric surgery clinic, they have to first be identified via a primary care provider, and so the study examined that exact step.

Speaker 3: Exactly. So this was a single center study at an academic bariatric program in Virginia, where Crystal was a fellow. They looked at adult patients seen in affiliated primary care clinics over a five-year period, and identified anyone who met the NIH criteria for bariatric surgery. And out of that group, about 4,700 patients were eligible and were [00:08:00] identified as potential candidates, but only about 5% were actually referred to a bariatric surgeon.

Speaker 2: Yeah, and again, similar to the first study, this is pretty striking, right? Because at this point, these are patients who are already engaged in care. They're, they're at least seeing a primary care provider within this system. They meet the medical criteria for bariatric surgery at the time, and still 95% of these are not getting referred.

Speaker: Right, Dr. Martin. And when you break that down further, you see some really clear patterns. Women were more likely to be referred than men, and importantly, Hispanic patients were less likely to be referred compared to both Black and Caucasian patients.

Speaker 4: And then again, insurance comes back into the picture, just like in our last paper In this cohort, about 40% of them were self-pay, meaning uninsured.

But when you examine specifically the Hispanic population, that number jumps to almost [00:09:00] 75% that were self-pay.

Speaker 3: And Crystal, that's really important context when you interpret the referral patterns. All taken together, the patients most likely to be referred were non-Hispanic, females, older, had a higher BMI, were insured, and had fewer comorbidities.

Speaker: Now, it is interesting that those with fewer comorbidities were less likely referred. This could highlight some referral decisions made by the PCPs that could be influenced by perceived surgical risk.

Speaker 4: You know, one thing that was really important structural detail is that at the institution at the time, self-pay was not accepted for patients.

So if you're a primary care provider and your patient doesn't have insurance, there was essentially no way for you to refer them to the surgical clinic within that health system, which sort of created more work for patients who were eligible for bariatric surgery and their PCP by simply replacing, you know, a referral to a surgery center that would [00:10:00] actually accept the self-pay option, which I don't know how much you know about that part of Virginia, but it's pretty rural.

So that could create quite the hindrance for patients.

Speaker 2: Yeah, that was a really interesting finding, Crystal. When we see that the Hispanic patients were significantly less likely to be referred, I think it's pretty clear that it wasn't just about the patient or the provider preference, but it's also about structural and socioeconomic limitations, particularly insurance status and institutional policies like not accepting self-pay that you just mentioned, that, that certainly confound th-this data.

Speaker 3: Certainly. And additionally, there's a lot of other factors we can't fully capture in a retrospective study like this one. You know, things like patient preference or hesitation about surgery, perceptions about safety and efficacy, whether the PCP even discussed bariatric surgery or obesity treatment in their clinic.

We all know that primary care clinics are known for their constraints on time and [00:11:00] quotas for number of patients that have to be seen. There's of course language barriers to certain populations, Hispanic populations, as we mentioned, and cultural perceptions of obesity and surgery. All of these could influence whether a referral even happens.

Speaker: Exactly, Dr. Dan. And similar to the previous paper, this study is also a retrospective study, so we can't establish causality, and it's from a single academic center and rural region, so it may not generalize to every population.

Speaker 4: But the message is still clear that disparities in bariatric surgery don't just happen at the level of who gets surgery.

They start much earlier at the level of who even gets referred. And when you look at this study alongside the paper that we just discussed beforehand by Dr. Martin, it tells an even bigger story. First, there are certain populations that are less likely to be referred for metabolic compared to surgery.

And then even if they are referred, they may face very significant [00:12:00] insurance and access barriers, and ultimately they are less likely to undergo surgery despite having a very clear indication

Speaker 2: for surgery. Yeah, exactly. And, and these disparities we're seeing aren't just one step or one factor. It's happening at every stage of the pipeline that the patients have to navigate.

I, I think another big takeaway here is that improving access isn't just about expanding surgical capacity, right? It's about educating primary care providers, addressing insurance barriers and insurance access, and making sure patients actually have a pathway into the system and understand how that pathway works.

I'd be curious, Crystal, if you, if you redid this analysis today, do you think it would look the same, better, or worse?

Speaker 4: I think it would look better. After this was published, I actually shared this data with the chairs of the two primary care arms at the health system, and they actually were very interested in this data because they were [00:13:00] completely unaware of it.

And so I think it would look better. Maybe there should be a follow-up study. Let's do it.

Speaker 2: Yeah. And I think that that's a great lesson, too, that probably a big part of your job as a bariatric surgeon is often reaching out to your primary care providers and giving them a little education on bariatric surgery and referrals.

Right.

Speaker: All right. So we've talked about disparities in who gets surgery and who even gets referred, but this next paper takes a step back and asks a different question: Where do these disparities actually come from? Because a big part of this story is weight stigma. So this next study by Wang and colleagues was published in 2025.

It is a systemic review of randomized control trials looking at interventions to reduce weight stigma.

Speaker 3: And that's a pretty big deal, Katie, because instead of just describing the problem, this paper is really asking what actually works to change attitudes. And I've got my own [00:14:00] ideas. We're gonna talk about the paper first.

But the, the authors looked at 56 randomized controlled studies, and they grouped the interventions in about eight different strategies.

Speaker 2: Yeah. And, and one of the main strategies and, and probably the most important one is shifting how we, uh, and the population thinks about the causes of obesity. So instead of framing obesity as purely about personal responsibility and blame, uh, these interventions emphasize things like genetic causes, biology, uh, socioeconomic and environmental causes.

And studies show that even something as simple as, uh, reading material or a short lecture, uh, for example, on food addiction could lead to more empathetic attitudes, especially in the student populations that were studied.

Speaker 4: You change the cause, you change the blame. And now that ties into another major [00:15:00] category, weight-inclusive approaches.

This focuses less on weight loss itself and more on things like healthy behaviors, body acceptance, self-compassion. So instead of saying, "You need to lose weight," it's more about how do we support overall health? These interventions include things like showing images of people in larger bodies being active, or sessions on mindfulness and self-compassion.

I

Speaker: like how they're shifting the goal from weight to a focus on an overall health here. An even more psychological approach is based on the cognitive dissonance theory. This is the idea that when your beliefs and your actions don't line up, it creates discomfort, and you're motivated to resolve that. So some interventions used intentionally created that tension.

For example, they asked participants to reflect and confront their own biases, leading to a shift in their own attitudes. So it's making people realize, "Wait, this doesn't actually align with how I see myself."

Speaker 3: There were also interventions [00:16:00] focused on building connection, so creating shared identity or common ground with people living with obesity.

Often, this is done through personal narratives and group classes. This led to improvements in self-stigma on weight. And this, you know, I r- look at things like this, I can't help but think of the Louis Aronne, as many of you know, is a very respected figure in obesity medicine. He said obesity is probably the only disease where patients actually exhibit self-bias, meaning there's a lot of bias, a lot of stigma out there.

But when you're told your entire life that this is your fault and you're to blame, oftentimes you wonder if you deserve the care to treat your disease. And that's really an important thing to consider, and those things have to be unrooted.

Speaker 2: Well, and I mean, e- even look at how long it took us to change simple things like stop saying 30-something-year-old obese female, and it's, you know, a, a patient with obesity.

But this group [00:17:00] reported relatively encouraging results, showing about 93% of the studies had some improvement in weight stigma compared to their control groups. And although this sounds great, I do think it's important to interpret that very carefully.

Speaker 4: Agreed. Most of these studies are measuring attitudes as they're looking at changes in survey response or implicit or explicit bias.

This is more difficult to translate to real-world behavior or decision-making and, of course, patient outcomes.

Speaker: Yeah. So for instance, someone might say they feel less biased in these randomized control trials, but does that actually change whether they refer a patient for surgery or whether they seek out bariatric treatment themselves?

Speaker 3: Exactly, Katie, and that's still a big gap in the literature. Another limitation is that most of these studies were done in Western high-income countries, very much like the United States, so we don't fully understand how these interventions apply across [00:18:00] different cultures and low and middle-income settings.

Speaker 2: But even with those limitations, this paper does give us some important ideas in telling us that the weight stigma is not fixed. It's malleable, and it's intervenable. It's something that we can change through education, empathy, and structural shifts in how we discuss obesity. Although I, I certainly think we have a long, long road to go on that.

And, and even among our specialty, I think as surgeons, we see weight stigma, you know, every day. I think in how we talk about, you know, some of our patients that came in and, you know, this, this case was tough, you know, because of this patient's history and body habitus, and, and we still tend to do a lot of, a lot of patient blaming and shaming, even, even as physicians and surgeons.

Speaker: Yes, I, I agree. And to wrap things up on this episode, herein we discussed disparities on who gets [00:19:00] surgery, disparities on who gets referred, and discussed some of the underlying drivers of how weight stigma and bias can shape the way patients are perceived, how providers make decisions, and how comfortable patients are with seeking care.

Speaker 4: Yeah. And when you line all of those things up, it becomes very clear that this isn't just a patient or a system level issue. It's really a combination of both. It's a combination of structural barriers like insurance and access, provider level factors like referral patterns and implicit bias, which I could go into a whole, like, dissertation about.

And then there's patient level factors like self-stigma and cultural perceptions. But these papers do point us toward where we can start: improving insurance coverage and access pathways, increasing education and awareness among primary care providers, and actively working to reduce weight stigma, both in healthcare and more broadly in society.

Speaker 2: And I think one of the more [00:20:00] hopeful takeaways is from that last paper, that stigma isn't fixed. Uh, it's something we can actually intervene on and change. Uh, and if we can start to address this bias and improve access at each step, from eligibility to referral to treatment, uh, then I think we can start to chip away at that huge gap that we're still seeing between who needs bariatric surgery and who actually receives it

Speaker 3: Yeah, man, I believe these studies, and I gotta congratulate you and Crystal on your wonderful studies.

These are really important to defining the problem. You know, they say you gotta name it to tame it, and this kinda gives it a little bit of a definition and, and outlines the headwinds that we are facing. But we also have to consider how our generation will respond to these headwinds because ultimately I believe that technology, data analytics, and decision support will be the catalysts.

These catalysts will lead [00:21:00] to, uh, referrals based not on lack of education or stigma or bias, but based on understanding of the eligibility, the safety, and the efficacy of the various treatments, including obesity medications and bariatric surgery. And ultimately, that's the goal. We gotta make sure that these patients who truly benefit from the procedures and the therapy actually have a fair opportunity to receive them.

Speaker: Very well said, Dr. Dan. And thank you all for listening. And as always, all together now.

Speaker 3: Dominate the- Dominate- Dominate- We're never gonna get that. ... the day. That's our trademark,

Speaker: so.

Speaker 4: We tried. We tried.