The Role of Body Appreciation in the Decision to Complete Metabolic and Bariatric Surgery Among Ethnically Diverse Patients

Metabolic and bariatric surgery (MBS) is an evidence-based safe, effective treatment for obesity. However, only half of referred or eligible persons complete the procedure for unknown reasons. The proposed study examined the association between the degree of body appreciation and the decision to complete MBS by ethnicity. This prospective cohort study included 409 participants who had been referred to a bariatric surgeon or an obesity medicine program between August 2019 and May 2022. Participants completed a survey about health behaviors and psychosocial characteristics, including body appreciation by MBS completion status (Y/N). Multivariate logistic regression models generated adjusted odd ratios (aOR) and 95% confidence intervals (CIs) of body appreciation among MBS completers vs. non-completers. The sample mean age was 47.18 years (SD 11.63), 87% were female. 39.6% identified as non-Hispanic White (NHW), 38.5% as non-Hispanic Black (NHB), and 17.6% as Hispanic. Over a third of the sample (31.05%, n = 127) completed MBS. “Often” experiencing body appreciation was the most significant predictor of MBS completion (aOR: 28.19, 95% CI: 6.37–124.67, p-value < 0.001), followed by “Sometimes” (aOR: 20.47, 95% CI: 4.82–86.99, p-value < 0.001) and “Always” (aOR: 13.54, 95% CI: 2.55–71.87, p-value < 0.01) after controlling for sex, age, and race/ethnicity. There was not a significant interaction between body appreciation and race/ethnicity (p-value = 0.96). Results showed a significant association between body appreciation and MBS completion, controlling for sex, age, and race/ethnicity. MBS clinical settings may want to assess body appreciation as a pre-operative screener among ethnically diverse patients.

Studies have found significant disparities between the general patients with obesity and the subset that have access to and/or receive MBS [40][41][42][43]. Despite being medically eligible for MBS, socioeconomic factors play a large role in deciding who completes the procedure. A study by Martin et al. found that those eligible for MBS had significantly lower family incomes, lower education levels, less access to healthcare, and were more likely to be ethnic minorities [42]. Similarly, Tang et al. reported factors that influence the acceptance of MBS includes patients with heavier weight, higher BMI, family support, medical insurance reimbursement, past surgical history, family history of T2DM, and obesity-related comorbidities and symptoms [43].
Another factor that may influence the decision to receive MBS is body appreciation. Several studies have discovered that perceptions of being overweight are more common in NHW women than in NHB and Hispanic women [44,45]. In a study of over 1700 women with overweight or obesity aged 40 years and older, NHB and Hispanic women had greater body satisfaction than NHW women [46]. Compared to NHW women, NHB women are less worried about their weight [45]. They often describe less pressure to be thin, less disappointment with their weight, and more acceptance of having larger bodies [45,47,48]. A study found that while NHB women are weight conscious, they lack negative social pressure and have a positive body image [49].
Similar to NHBs, Hispanics are more satisfied with their bodies and less concerned about weight [50][51][52][53]. For Hispanics, particularly Hispanic women, a larger body size is connected to affluence, prosperity, and harmony, contributing to a larger, more rounded body shape as the ideal [50]. One study found that Latina patients had a greater interest in improving the appearance of their skin and energy levels rather than the desire to reduce body size [51].
With the differences in cultural attitudes to body aesthetics, body appreciation may influence whether a patient completes MBS. Indeed, cultural attitudes, beliefs, and traditions about obesity, body size, and shape vary among ethnic minority groups compared to NHWs [39]. Body appreciation is an aspect of positive body image that indicates one's acceptance and respect for one's body while rejecting unrealistic body ideals [54]. As it predicts indices of well-being, body appreciation has been associated with engagement in more positive eating, exercise, and health behaviors [54]. Body appreciation is also protective against various psychiatric pathologies, including depression, anxiety, and disordered eating behaviors [55]. Furthermore, body appreciation appears to be a viable target for health interventions [56].
To date, no study has assessed the relationship between body appreciation and MBS completion/non-completion by ethnicity. The primary objective of this analysis was to understand if body appreciation is associated with the decision to complete MBS; a secondary objective was to examine how body appreciation varied by race/ethnicity. Based on the literature, we hypothesized that body appreciation would influence the completion of MBS among NHW participants, but not NHB or Hispanic participants.

Study Design
This prospective cohort study utilized data from the Bariatric Health Study (NIH/NIMHD 5R01MD011686). The project has two aims: (1) identify socioecological characteristics associated with patient-directed completion or non-completion of MBS; (2) determine the short (6-month)-, mid (12month), and long (24-month)-term change in these characteristics and how they relate to weight loss and comorbidity resolution in an ethnically diverse patient population in the North Texas geographic area. Here, we report the relevant results of the phase one study.

Study Population
The study population includes 409 patients, 18-78 years of age, who were medically referred for MBS. To be eligible for the study, participants must (a) meet NIH criteria [57] to qualify for MBS ((BMI ≥ 40 kg/m 2 , BMI ≥ 35 kg/m 2 and at least one existing comorbidity (e.g., elevated blood pressure, hypercholesterolemia, etc.) or BMI ≥ 30 kg/m 2 with T2DM that is difficult to control with lifestyle and medical therapies); (criteria verified by bariatric clinical staff)); and (b) consent to participate in the study.

Study Procedures
All patients in the Bariatric Health Study were medically referred by their primary care physicians to an MBS practice or an obesity care clinic. Eligible patients must complete a mandatory MBS educational seminar before they can schedule surgery. Patients were recruited to the Bariatric Health Study by clinic staffs during these seminars.
Other recruitment strategies were also utilized as follows: (1) flyers and brochures were posted at various obesity clinics; and (2) research study staff created and maintained a Facebook page to demonstrate the study information and to respond to any questions of interested participants.
The study had 46 subjects who were recruited for the study but chose to not participate. These subjects ultimately decided not to pursue MBS and therefore decided not to participate.
Eligible patients first participated in a 15 to 20-min phone or video interview where clinical and trained study team members administered the verbal proportion of questionnaires. As patients were not required to be English speaking, there was a Spanish-speaking team member who conducted interviews in Spanish and translated as necessary. Upon completion of the call, participants were directed to complete the self-administered online questionnaire, which was delivered via email through REDCap. Participants are compensated with an e-gift card ($50 for baseline/pre-surgery interview) for their participation through email after the completion of questionnaires.

Measures
Primary Outcome Variable MBS completion was selfreported and verified by the recruitment site. Those who received MBS were labeled as "completers," and those who did not receive MBS were labeled as "non-completers." Primary Exposure Variable Body appreciation, the primary exposure or independent variable, was assessed via the 13-item Body Appreciation Survey (BAS) [2]. It is a validated survey to assess acceptance and respect for the body [58]. The BAS uses a 5-point Likert scale with responses ranging from 1 (Never) to 5 (Always). In accordance with other studies, body appreciation was converted into an average scoring range with higher scores indicating better body appreciation, as the BAS does not have an overall item [3][4][5]16]. "Never" served as the reference group for the BAS. This was due to the literature supporting low body appreciation as a motivating factor for MBS completion [54,[58][59][60][61][62]. Similarly, the literature states NHBs and Hispanics have greater body appreciation than NHWs [46][47][48][49][50][51]. The BAS was administered as a component of the standardized online questionnaire battery before those labeled as "completers" received MBS. For those labeled "non-completers," after the BAS was administered, their participation in the study was concluded.

Covariates
Demographic Characteristics Age, sex, race, ethnicity, marital status, education, insurance, employment status, and nicotine use were collected. All variables were self-reported and collected through standardized online questionnaires.
Anthropometric Measures BMI was calculated based on the weight and height that were pre-MBS self-reported and collected through standardized forms.

Statistical Analysis
Descriptive analysis included frequencies and percentages for all categorical variables. The mean for each item in the BAS was explored with ethnicity and MBS groups (completers and non-completers).
Univariate logistic regression models estimated the odds ratios (ORs) and 95% confidence intervals (CI), respectively, for body appreciation and or race and ethnicity by MBS completion. Multivariate models computed the adjusted odds ratios (aOR). The model was adjusted for age, sex, and race and ethnicity. An interaction term (race/ethnicity*BAS) was included in the multivariable logistic regression model to assess if there was a modifying effect of race/ethnicity. All analyses were conducted using SAS version 9.4 statistical software (SAS Institute, Cary, NC). Two-sided P-values < 0.05 was considered significant.

Sample Size and Power Analysis
This study aimed to recruit at least 400 participants, which will provide approximately 80% power at the alpha level of 0.01 if the effect accounts for 3% of the total variance relative to the model-specific error term (i.e., R 2 = .03). Since we were able to recruit 409 patients in the phase I study, a post hoc power analysis was performed and found our study had > 99.9% statistical power to detect differences between completers and non-completers at the alpha level of 0.05.

Results
Out of 409 participants, 127 completed MBS (31.05%) and 282 participants did not (68.95%). Of the cohort, about 29% of participants were between the ages of 40 to 49 years (47.6 ± 11.6), 87% were female, and around 40% were NHW. The mean BMI was 45.7 ± 10.3 kg/m 2 . Almost 45% of participants had private insurance and 45% were employed. About 48% of participants were married. For 44% of participants, the highest education received was college (Table 1). Table 2 shows the results of the descriptive analysis of body appreciation between the completers and noncompleters. Only two statements were significant. The statement "I feel good about my body," differed (p-value < 0.05) with completers having a higher body appreciation (M = 1.97) than non-completers (M = 1.88). The statement "I do not allow unrealistically thin images of women presented in the media to affect my attitudes toward my body," differed (p-value < 0.05) with completers having a higher body appreciation (M = 2.36) than non-completers (M = 2.30).
Nine of the thirteen body appreciation scale items differed by race and ethnicity (Table 3). In the post hoc comparisons, seven items differed for the NHB cohort, while one item differed for Hispanics. Specifically Univariate and multivariate logistic regression models showed those with a mean BAS score of "Often" were most likely to complete MBS when compared to those who had a mean BAS score of "Never" (cOR: 33.13, 95% CI: 7.56-145.14, p-value < 0.001 and aOR: 28.19, 95% CI: 6.37-124.67, p-value < 0.001). For those with a mean BAS score of "Sometimes," the odds of MBS completion were greater when compared to those who had a mean BAS score of "Never" (cOR: 24.94, 95% CI: 5.91-105.19, p-value < 0.001 and aOR: 20.47, 95% CI: 4.82-86.99, p-value < 0.001). Those with a mean BAS score of "Always" were more likely to complete MBS when compared to those who had a mean BAS score of "Never" (cOR: 15.65, 95% CI: 2.98-82.06, p-value < 0.01 and aOR: 13.54, 95% CI: 2.55-71.87, p-value < 0.001). For those with a mean BAS score of "Seldom," the odds of MBS completion were greater when compared to those who had a mean BAS score of "Never" (cOR: 15.35, 95% CI: 3.45-68.27, p-value < 0.01 and aOR: 12.12, 95% CI: 2.69-54.59, p-value < 0.01). Race/ ethnicity was not an independent predictor of MBS completion (all p > 0.05) ( Table 4). The overall interaction between ethnic groups and BAS was insignificant (P-interaction = 0.96).

Discussion
Results here showed an association between body appreciation and MBS completion, but did not vary by ethnicity. Specifically, body appreciation was greater among completers than non-completers. The lack of influence of race and ethnicity on the association between body appreciation and MBS completion is converse to our hypothesis that low body appreciation would be associated with more MBS completion among NHWs, but not for NHBs or Hispanics.
In this study, we found higher body appreciation associated with MBS completion. This differs from the literature, which supports body dissatisfaction as a factor motivating the decision to seek MBS [58][59][60][61][62]. Compared to a study that found body image dissatisfaction was a motivating factor in obtaining MBS, our study indicated a positive association between body appreciation and MBS [58]. Pearl et al. found patients reported high body dissatisfaction and desire for surgery to change the appearance of several body parts, including the stomach and thighs. "Myself" was the highest-rated motivating person when deciding to receive MBS [59]. Eck et al. found body dissatisfaction presents health behavior risks, such as using maladaptive eating habits instead of adaptive eating habits [60].
The results showed NHBs and Hispanics had a greater body appreciation than NHWs. The differences in body appreciation for NHWs and ethnic minority groups are consistent with prior studies [44][45][46][47][48][49][50][51]. Both NHBs and Hispanics had higher body appreciation than NHWs. Both, Libeton et al. found women tend to be motivated by physical appearance [63]. Brink and Ferguson found body image greatly influenced both men and women to seek MBS [64]. With the literature supporting body dissatisfaction as a motivating factor for MBS completion, NHBs and Hispanics having a greater body appreciation than NHWs, and a high non-completion rate among ethnic minorities compared to NHWs, "Never" was selected as the reference group for the BAS in the univariate and multivariate logistic regression models.
To understand if body appreciation influences patients to seek MBS, it is essential to acknowledge the reasons people undergo MBS as well as the characteristics of specific patient populations. Previous research has found that health issues and concerns dominate the motivation for MBS completion [62][63][64][65][66][67]. Health concerns included the risks of future health and medical problems [62], current medical ailments [64], obesity-related comorbidities, including hypertension and urinary incontinence [65], eating habits [66], and weight loss [67].
Most people completing MBS are NHW women, with a median age range of 35-45 years old, with either severe obesity or obesity with comorbidities [34,37,39,67,68]. Similar to other studies, over 80% of our participants who underwent MBS were females [69] and had an average age   [70]. Unlike other studies reporting a surgery completion of 50%, only about 31% of the medically referred patients completed MBS [15,[32][33][34]36]. Additionally, our study had a more diverse population, including 18% Hispanic, which reflects the growing Hispanic/Latinx population in the USA [71].
Our study provides insight into how body appreciation varies by race and ethnicity. Compared to NHBs, NHWs appear to have a lower body appreciation, followed by Hispanics. While our results did not indicate an influence of race and ethnicity on the association between body appreciation and MBS completion, it is important to investigate further the factors influencing patients' decision to obtain MBS. In our sample, only one-third of the medically referred patients completed MBS, and studies show that ethnic minority groups are less likely than NHW to complete MBS despite having higher rates of severe obesity and comorbidities [32,33,36].
Several studies have found that most patients who do not complete MBS, the reason is "unknown" [39]. Elucidating these "unknown" reasons may explain why NHBs and Hispanics are less likely than NHWs to complete MBS and potentially improve ethnic disparities. One potential explanation for the low utilization rate of MBS is the concern for increased peri-operative complications because of current health issues. As mentioned previously, obesity is associated with a greater risk of comorbidities, including T2DM, hyperlipidemia, hypertension, or nonalcoholic fatty liver disease [2][3][4]15]. There is an increased rate of most of these conditions among minority groups compared to NHWs [72][73][74][75]. The prevalence of diagnosed T2DM is greatest among NHBs (13.2%), followed by Hispanics (12.8%) and NHWs (7.6%) [72]. From 2015 to 2016, NHBs adults aged 20 and over were the most likely to have hypertension at 40.3%, compared to NHWs at 27.8% and Hispanic at 27.8% [73]. Similarly, NHBs have the highest rate of cardiovascular disease, with about 47% impacted [74]. In matters of cancer, NHBs have higher death rates than all other racial/ethnic groups for many, although not all, cancer types. Also, NHBs are more likely to die from breast cancer than NHWs, despite the comparable rates of breast cancer [75].
Given the larger societal factors surrounding MBS, healthcare providers should focus on providing appropriate healthcare education that acknowledges racial and socioeconomic factors. Additionally, healthcare providers should focus on both obesity-related health risks and options for surgical treatment that will ultimately improve the acceptance of MBS.
Health disparities expose the interaction among numerous aspects, including social determinants of health, behavior, biology, and genetics-all of which can significantly impact health, including risk and outcomes [75]. Due to social, environmental, and economic disadvantages, NHBs and Hispanics are disproportionately burdened by various health conditions. The burden of ethnic health disparities contributes to an increase in adverse events, hospitalizations, healthcare costs, and deaths among minority groups [72,75]. As obesity is associated with increased risk for many diseases and health conditions, MBS can help improve ethnic health disparities, given MBS is an evidence-based, safe, and effective long-term treatment for severe obesity and weightrelated health problems [21,76].

Strengths and Limits
The study findings presented here must be interpreted in the context of several potential limitations. First, most participants were recruited from one US geographic region. This may lead to a lack of generalization to other populations and potential misrepresentation of participants considering MBS. Another limitation was the data was based on self-reports, therefore, dependent on the honesty and accuracy of the participants on questions that could cause discomfort, leading to recall or reporting bias. However, the research staff verified patients' health record to affirm responses. Lastly, due to data limitation, we did not collect comorbidity information resulting in residual confounding as health factors are important factors for MBS completion. Despite these limitations, our study has many strengths. The major strength of this study is using the prospective study design; thus, we can establish the temporal relationship between body appreciation and the decision to complete MBS. Secondly, the study has a diverse population, so there was adequate statistical power to examine ethnic differences. Additionally, we were able to include socioeconomic variables, such as insurance and education status, which are factors that influence the acceptance of MBS. Lastly, our study is the first study in the literature to examine the role of body appreciation in the decision to complete MBS among an ethnically diverse sample using a standardized measurement tool.

Conclusions
This prospective cohort study showed an association between body appreciation and MBS completion when controlling for sex, age, and race/ethnicity. The preliminary findings suggest body appreciation varies by race and ethnicity, but further research is needed to understand if race and ethnicity contribute to the lower rates of completion of MBS in this patient population. Sociocultural differences in weight, body size, and shape may impact individual choices to complete MBS and access non-surgical treatments for obesity. Understanding the reasons for high non-completion rates for MBS among ethnic minority groups may enable clinicians to individualize interventions and pre-MBS education to optimize motivation and help patients achieve optimal body health.

Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Minority Health and Health Disparities (NIH/NIMHD Grant number 5R01MD011686).

Statement of Human and Animal Rights
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent Informed consent does not apply.

Conflict of Interest
The authors declare no competing interests.