A framework for studying race-based disparities in the use of metabolic and bariatric surgery for the management of pediatric obesity

Pediatric obesity is undoubtedly a public health crisis in the United States, which disproportionally affects racial/ethnic minorities. Among the greater than 13 million children and adolescents diagnosed with obesity, 4.5 million suffer from its severe form.^1,2 Over the past decade, studies have demonstrated greater benefits for pediatric patients treated with metabolic and bariatric surgery (MBS) relative to those treated with medical therapy or lifestyle interventions alone,³ especially among the cohort with severe disease. This was further emphasized by the American Academy of Pediatrics (AAP) in a recent policy statement, where they recommend that pediatricians “advocate for increased access for pediatric patients of all racial, ethnic, and socioeconomic backgrounds to multidisciplinary programs that provide high quality pediatric metabolic and bariatric surgery”.⁴

This issue is of critical importance, especially as MBS remains largely underutilized,⁵ and marked race-based disparities in its use have been well documented.⁶ Our knowledge of the true drivers behind these disparities is further complicated by the complex relationship between race/ethnicity and insurance previously documented, with studies demonstrating higher use of MBS among White adolescents with Medicaid compared to their privately insured counterparts, while the opposite is true for Black and Hispanic patients.^6,7

In order to eliminate these disparities, we must first delineate where they occur along the care journey of a child or adolescent with obesity. Without a thorough understanding of the forces driving these disparities, any attempts at reducing them, albeit well-intentioned, are likely to have limited success. Importantly, the goal of this piece is not to hypothesize on the causes behind previously documented race-based disparities, but rather to propose a framework for the objective appraisal of each stage along the care continuum of pediatric obesity, so that both proponents and opponents of fundamental change can have at their disposal the data necessary to stake their claims and device useful policy and practice changes.

Understand differences in patients’ and parents’ views of obesity, its effects and management options

Several previous studies have documented disparities in access to preventive care and the quality of that care for children of racial/ethnic minorities,⁸ which can certainly contribute to a decreased rate of diagnosis and counseling of obesity among these populations. Patient-related factors can similarly play a role in their willingness to pursue MBS. For example, a study among adult populations found that Black patients with obesity were less likely to have considered MBS prior to presenting to their primary care office compared to White patients,⁹ largely due to a perception of surgery as a high-risk method of last resort.^9,10 We believe primary studies combining large database analysis with surveys and direct interviews with patients and providers (i.e. mixed-methods research) are needed in order to explore the awareness and level of understanding of patients and their families regarding their diagnosis, as well as its management options. Such efforts should specifically address the following key questions:

1. Patients’ and parents’ views of obesity and its impact on their quality of life, to include pediatric-specific factors such as participation in school sports, mental health, bullying in school or via social media, etc.

2. Patients’ and parents’ understanding of the short and long-term deleterious effects of obesity to include higher prevalence of cardiovascular diseases and lower life expectancy,^11,12 as well as pediatric-specific conditions such as slipped capital femoral epiphysis (SCFE) and Blount disease.¹³

3. Patients’ and parents’ views and understanding of the different management modalities, to include MBS, as well as their ability and limitations to engage in alternative lifestyle changes and medical management options.

Understand differences in referral patterns for multidisciplinary and surgical evaluation

Once a diagnosis of severe obesity has been established in a child or adolescent, a referral to a multidisciplinary weight center with MBS capabilities should follow. However, it is unclear if racial/ethnic minorities, as well as patients of lower socioeconomic status (SES), are referred by their pediatricians or family care physicians at equal rates as their White counterparts, and if referred, whether they ultimately pursue these consultations at similar rates. Studies among adult patients have in fact found that primary care physicians are less likely to discuss MBS with Black and Hispanic adult patients compared to Whites, even though non-White patients were more likely to consider it once presented by their providers.⁹

The contribution of provider-related factors such as obesity training, race and weight bias, and their own weight status to the likelihood of referring pediatric patients of different race/ethnicity, insurance coverage, and SES for multidisciplinary evaluation remains similarly unexplored, though recently published data have highlighted the relationship between formal obesity training and increased provider confidence with all modalities of obesity management, to include discussing MBS and caring for pediatric patients after they undergo MBS.¹⁴ The effect that differences in the geographic availability of multidisciplinary weight centers might have on both providers’ and patients’ likelihood of pursuing referrals is similarly unknown.

Studies employing mixed methodology are again needed in order to elucidate the existence of race-based differences in referral for multidisciplinary evaluation, and well as their relationship with provider and patient-related views of obesity and MBS. These studies should explore the following specific questions:

1. Relationship between primary pediatric providers’ implicit and explicit racial and weight bias, and their likelihood of referring patients of different race/ethnicity, insurance coverage, and SES for multidisciplinary evaluation.

2. The specific role that current reimbursement models for both private and government-sponsored insurance plays on pediatric providers’ likelihood of referring patients for multidisciplinary evaluation.

3. Geographic differences in the availability of multidisciplinary weight centers and surgeons willing and capable of caring for pediatric patients, and the differential effect that this variability might have on patients of different race/ethnicity, insurance coverage, and SES.

4. Likelihood of patients of different race/ethnicity, insurance coverage, and SES to pursue referrals for multidisciplinary evaluation when provided, as well as the role of existing barriers including cultural views and stigma, financial limitations, availability of transportation and parental time off from work, etc.

Understanding differences in the likelihood of proceeding with MBS

Even if referral patterns were equal, it is unknown whether racial/ethnic minority children and adolescents with obesity would proceed with MBS at similar rates as their White counterparts, though studies exploring this question among adults have found racial/ethnic minority patients were equally likely to undergo MBS once evaluated at a multidisciplinary weight center.¹⁵

The relationship between surgeon bias and their ultimate decision to offer MBS to patients of different race/ethnicity, insurance coverage, and SES, has also not been directly explored, though it is not unreasonable to hypothesize it may impact clinical practice. For example, a study using the MBSAQIP database found Black patients were more likely to receive a prophylactic IVC filter prior to MBS, despite having lower prevalence of venous thromboembolism risk factors.¹⁶ Another study found that Black patients were more likely to undergo amputations for lower extremity claudication than White patients, and this disparity was more pronounced among high volume surgeons.¹⁷ Studies like these highlight the effect that provider racial bias (whether implicit or explicit) can have on practice patterns, and merit further consideration. Another factor potentially influencing surgeons’ likelihood of offering MBS to patient who are racial/ethnic minorities as well as those with government-sponsored insurance may be a perceived higher rate of postoperative complications among these populations, though studies exploring this relationship have provided mixed results at best.^18–22 Moreover, when evaluating outcomes it is important to account not only for race/ethnicity and insurance coverage, but for more fundamental social determinants of health such as employment and availability of healthy foods and safe play spaces, which may themselves be the primary drivers associated with potential differences in outcomes.

In the end, we cannot simply translate findings from adult studies to the pediatric population, particularly given the complex interplay between patients’ and parental views, consent, and ascent, and we should strive to ascertain these factors by direct examination of all pertinent stakeholders. Studies should specifically address the following questions:

1. The likelihood of pediatric patients of different race/ethnicity, insurance coverage, and SES to proceed with MBS if recommended, as well as existing barriers including perceived risks, financial limitations, availability of social and family support structures, etc.

2. The influence of surgeon racial bias and perceived surgical risk in their likelihood of offering MBS to patients of different race/ethnicity, insurance coverage, and SES.

3. The specific role that current reimbursement models for both private and government-sponsored insurance plays on the following:

   1. The likelihood that multidisciplinary weight centers will accept and/or actively pursue patients of different race/ethnicity and SES.
   2. A pediatric or bariatric surgeon’s likelihood to offer MBS to patients of different race/ethnicity, insurance, and SES.

Conclusion

Modest progress has certainly been made in ameliorating healthcare disparities since the report by the Institute of Medicine titled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” was published in 2003,²³ with a recent study, for example, finding previously identified race-based disparities in the use of panniculectomies were eliminated among adult patient who underwent the procedure after MBS, which supports the importance of access to care as a potential equalizer of healthcare disparities.²⁴ Nevertheless, without a systematic approach for studying the drivers behind documented race-based disparities in the use of MBS among pediatric patients with severe obesity, we are likely to embark on misguided and ineffective interventions that ultimately continue to deny this vulnerable population what may be the most effective treatment for their disease. If there’s one thing that has become abundantly clear during the recent times of racial reckoning in the U.S., is that blind acceptance of the status quo is no longer tolerable. We must seek to understand the forces behind the racial inequities that permeate our society and healthcare system, so we can move to swiftly addressing them, and hopefully one day, eliminating them altogether.