Featured Article| Volume 225, ISSUE 4, P609-614, April 2023

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

Published:September 26, 2022DOI:


      • We interviewed 45 patients and providers (surgeons, dietitians, health psychologists, PCPs).
      • SES barriers after bariatric surgery included employment, income, and transportation challenges.
      • Unsafe/inconvenient neighborhoods and limited health literacy were also barriers.
      • Interventions targeting these factors are needed to support bariatric surgery patients.



      Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.


      We performed semi-structured interviews with bariatric surgery patients and providers from April–November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.


      24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.


      Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.


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        • Estimate of bariatric surgery numbers
        Date: 2011-2018
        Date accessed: September 22, 2020
        • Schauer P.R.
        • Bhatt D.L.
        • Kirwan J.P.
        • et al.
        Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes.
        N Engl J Med. 2017; 376: 641-651
        • Mingrone G.
        • Panunzi S.
        • De Gaetano A.
        • et al.
        Bariatric surgery versus conventional medical therapy for type 2 diabetes.
        N Engl J Med. 2012; 366: 1577-1585
        • Maciejewski M.L.
        • Arterburn D.E.
        • Vs L.V.
        • et al.
        Bariatric surgery and long-term durability of weight loss.
        JAMA Surg. 2016; 151: 1046-1055
        • Chang S.H.
        • Stoll C.R.
        • Song J.
        • Varela J.E.
        • Eagon C.J.
        • Colditz G.A.
        The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012.
        JAMA Surg. 2014; 149: 275-287
        • Aminian A.
        • Fathalizadeh A.
        • Tu C.
        • et al.
        Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity.
        Surg Obes Relat Dis. 2021; 17: 208-214
        • Mora-Pinzon M.C.
        • Henkel D.S.
        • Miller R.S.
        • et al.
        Emergency department visits and readmissions within one year of bariatric surgery: a statewide analysis using hospital discharge records.
        Surgery. 2017; 162: 1155-1162
        • Funk L.M.
        • Suzo A.
        • Mikami D.J.
        • Needleman B.J.
        Two-year outcomes for medicaid patients undergoing laparoscopic Roux-en-Y gastric bypass: a case-control study.
        Obes Surg. 2014; 24: 1679-1685
        • Chen E.Y.
        • Fox B.T.
        • Suzo A.
        • et al.
        One-year surgical outcomes and costs for medicaid versus non-medicaid patients undergoing laparoscopic roux-en-Y gastric bypass: a single-center study.
        Surg Laparosc Endosc Percutaneous Tech. 2016; 26: 38-43
        • Dallal R.M.
        • Datta T.
        • Braitman L.E.
        Medicare and Medicaid status predicts prolonged length of stay after bariatric surgery.
        Surg Obes Relat Dis. 2007; 3: 592-596
        • Carbonell A.M.
        • Lincourt A.E.
        • Matthews B.D.
        • Kercher K.W.
        • Sing R.F.
        • Heniford B.T.
        National study of the effect of patient and hospital characteristics on bariatric surgery outcomes.
        Am Surg. 2005; 71: 308-314
        • Liu N.
        • Venkatesh M.
        • Hanlon B.M.
        • et al.
        Association between medicaid status, social determinants of health, and bariatric surgery outcomes.
        Ann Surg Open. 2021; 2: e028
        • Grover B.T.
        • Morell M.C.
        • Kothari S.N.
        • Borgert A.J.
        • Kallies K.J.
        • Baker M.T.
        Defining weight loss after bariatric surgery: a call for standardization.
        Obes Surg. 2019; 29: 3493-3499
        • Bailey H.
        • Agger W.
        • Baumgardner D.
        • et al.
        The Wisconsin Network for Health Research (WiNHR): a statewide, collaborative, multi-disciplinary, research group.
        Wis Med J. 2009; 108: 453-458
        • Imbus J.R.
        • Voils C.I.
        • Funk L.M.
        Bariatric surgery barriers: a review using Andersen's model of health services use.
        Surg Obes Relat Dis. 2018; 14: 404-412
        • Funk L.M.
        • Alagoz E.
        • Jolles S.A.
        • et al.
        A qualitative study of the system-level barriers to bariatric surgery within the veterans health administration.
        Ann Surg. 2022 Jan 1; 275: e181-e188
        • Babitsch B.
        • Gohl D.
        • von Lengerke T.
        Re-Revisiting andersen's behavioral model of health services use: a systematic review of studies from 1998-2011.
        Psycho Soc Med. 2012; 9: Doc11
        • Torain M.J.
        • Maragh-Bass A.C.
        • Dankwa-Mullen I.
        • et al.
        Surgical disparities: a comprehensive review and new conceptual Framework.
        J Am Coll Surg. 2016; 223: 408-418
        • Kahwati L.C.
        • Lance T.X.
        • Jones K.R.
        • Kinsinger L.S.
        RE-AIM evaluation of the veterans health administration's MOVE! Weight management program.
        Translat Behav Med. 2011; 1: 551-560
        • Hsieh H.F.
        • Shannon S.E.
        Three approaches to qualitative content analysis.
        Qual Health Res. 2005; 15: 1277-1288
        • Charmaz K.
        Constructing Grounded Theory: A Practical Guide through Qualitative Analysis.
        SAGE Publications, London2006
        • Vasileiou K.
        • Barnett J.
        • Thorpe S.
        • Young T.
        Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period.
        BMC Med Res Methodol. 2018; 18: 148
        • Broom A.
        Conceptualizing qualitative data.
        Qual Health Res. 2021; 31: 1767-1770
        • Durand-Moreau Q.
        • Gautier A.
        • Becouarn G.
        • Topart P.
        • Rodien P.
        • Salle A.
        Employment and professional outcomes in 803 patients undergoing bariatric surgery in a French reference center for obesity.
        Int J Occup Environ Med. 2015; 6: 95-103
        • Tarride J.E.
        • Breau R.
        • Sharma A.M.
        • et al.
        The effect of bariatric surgery on mobility, health-related quality of life, healthcare resource utilization, and employment status.
        Obes Surg. 2017; 27: 349-356
        • Bramming M.
        • Becker U.
        • Jorgensen M.B.
        • Neermark S.
        • Bisgaard T.
        • Tolstrup J.S.
        Bariatric surgery and risk of unemployment and sickness absence.
        Obes Surg. 2022; 32: 720-728
        • Chao G.F.
        • Yang J.
        • Thumma J.R.
        • et al.
        Out-of-pocket costs for commercially-insured patients in the years following bariatric surgery: sleeve gastrectomy versus roux-en-Y gastric bypass.
        Ann Surg. 2021 Nov 11;
        • Mahawar K.K.
        • Clare K.
        • O'Kane M.
        • Graham Y.
        • Callejas-Diaz L.
        • Carr W.R.J.
        Patient perspectives on adherence with micronutrient supplementation after bariatric surgery.
        Obes Surg. 2019; 29: 1551-1556
        • Eisenberg D.
        • Lohnberg J.A.
        • Kubat E.P.
        • Bates C.C.
        • Greenberg L.M.
        • Frayne S.M.
        Systems innovation model: an integrated interdisciplinary team approach pre- and post-bariatric surgery at a veterans affairs (VA) medical center.
        Surg Obes Relat Dis. 2017; 13: 600-606
        • Chao G.F.
        • Ehlers A.P.
        • Telem D.A.
        Improving obesity treatment through telemedicine: increasing access to bariatric surgery.
        Surg Obes Relat Dis. 2021; 17: 9-11
        • Docimo Jr., S.
        • Seeras K.
        • Acho R.
        • Pryor A.
        • Spaniolas K.
        Academic and community hernia center websites in the United States fail to meet healthcare literacy standards of readability.
        Hernia. 2022 Mar 27;
        • Miller-Matero L.R.
        • Hecht L.
        • Patel S.
        • Martens K.M.
        • Hamann A.
        • Carlin A.M.
        The influence of health literacy and health numeracy on weight loss outcomes following bariatric surgery.
        Surg Obes Relat Dis. 2021; 17: 384-389
        • Spreckley M.
        • de Lange J.
        • Seidell J.C.
        • Halberstadt J.
        Patient insights into the experience of trying to achieve weight-loss and future expectations upon commencement of a primary care-led weight management intervention: a qualitative, baseline exploration.
        PLoS One. 2022; 17e0270426