Bariatric surgery for obese children and adolescents: a review of the moral challenges

BMC Medical Ethics

Bjørn Hofmann¹ 

[1] Section for Health, Technology, and Society, University College of Gjøvik, PO Box 191, Gjøvik, N-2802, Norway

关键词: Moral;    Ethics;    Adolescents;    Children;    Bariatric surgery;   

Others  :  799955
DOI  :  10.1186/1472-6939-14-18

 received in 2012-04-30, accepted in 2013-04-22,  发布年份 2013

【 摘 要 】

Background

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

Discussion

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

Summary

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

【 授权许可】

   
2013 Hofmann; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]WHO: Obesity and Overveight. Geneva: World Health Organisation; 2003.
• [2]Orsi C, Hale D, Lynch J: Pediatric obesity epidemiology. Curr Opin Endocrinol Diabetes Obes 2011, 18(1):14-22.
• [3]Wang Y, Lobstein T: Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes 2006, 1(1):11-25.
• [4]Ibele AR, Mattar SG: Adolescent bariatric surgery. Surg Clin North Am 2011, 91(6):1339-1351.
• [5]de Vries J: The obesity epidemic: medical and ethical considerations. Sci Eng Ethics 2007, 13(1):55-67.
• [6]Ebbeling CB, Pawlak DB, Ludwig DS: Childhood obesity: public-health crisis, common sense cure. Lancet 2002, 360(9331):473-482.
• [7]Ludwig DS: Childhood obesity–the shape of things to come. N Engl J Med 2007, 357(23):2325-2327.
• [8]Garrett JR, McNolty LA: Bariatric surgery and the social character of the obesity epidemic. Am J Bioeth 2010, 10(12):20-22.
• [9]Daniels SR: Complications of obesity in children and adolescents. Int J Obes (Lond) 2009, 33(Suppl 1):S60-S65.
• [10]Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, Campbell KJ, Gao Y, Armstrong R, Prosser L, Summerbell CD: Interventions for preventing obesity in children. Cochrane Database Syst Rev 2011, 12:CD001871.
• [11]Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ: Interventions for preventing obesity in children. Cochrane Database Syst Rev 2005, 3:CD001871.
• [12]Livingston EH: Surgical treatment of obesity in adolescence. JAMA 2010, 303(6):559-560.
• [13]Dutta S, Morton J, Shepanrd E, Peebles R, Farrales-Nguyen S, Hammer LD, Albanese CT: Methamphetamine use following bariatric surgery in an adolescent. Obes Surg 2006, 16:780-782.
• [14]Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS, Strauss RS, Albanese CT, Brandt ML, Hammer LD, Harmon CM: Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004, 114(1):217-223.
• [15]Lagerros Y, Rössner S: Managing obesity–from childhood and onwards. Int J Pediatr Obes 2011, 6(Suppl 1):74-78.
• [16]Pratt JS, Lenders CM, Dionne EA, Hoppin AG, Hsu GL, Inge TH, Lawlor DF, Marino MF, Meyers AF, Rosenblum JL: Best practice updates for pediatric/adolescent weight loss surgery. Obesity 2009, 17(5):901-910.
• [17]Lau DCW, Douketis JD, Morrison KM, Hramiak Im SAMUE: Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ 2006, 176(Suppl 8):1-117.
• [18]Uli N, Sundararajan S, Cuttler L: Treatment of childhood obesity. Curr Opin Endocrinol Diabetes Obes 2008, 15(1):37-47.
• [19]Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, Summerbell CD: Interventions for treating obesity in children. Cochrane Database Syst Rev 2009, 1:CD001872.
• [20]Han JC, Lawlor DA, Kimm SY: Childhood Obesity – 2010: Progress and Challenges. Lancet 2010, 375(9727):1737-1748.
• [21]Whitlock EA, O'Connor EP, Williams SB, Beil TL, Lutz KW: Effectiveness of weight management programs in children and adolescents. Evid Rep Technol Assess 2008, 170:1-308.
• [22]Mitchell F: Obesity: Bariatric surgery in youth. Nat Rev Endocrinol 2012, 8(7):381.
• [23]Inge TH: Bariatric surgery for morbidly obese adolescents: is there a rationale for early intervention? Growth Horm IGF Res 2006, 16(Suppl A):S15-S19.
• [24]Inge TH, Xanthakos SA, Zeller MH: Bariatric surgery for pediatric extreme obesity: now or later? Int J Obes (Lond) 2007, 31(1):1-14.
• [25]Keidar A, Hecht L, Weiss R: Bariatric surgery in obese adolescents. Curr Opin Clin Nutr Metab Care 2011, 14(3):286-290.
• [26]Pratt JSA, Lenders CM, Dionne EA, Hoppin AG, Hsu GLK, Inge TH, Lawlor DF, Marino MF, Meyers AF, Rosenblum JL, Sanchez VM: Best practice updates for pediatric/adolescent weight loss surgery. Obesity (Silver Spring) 2009, 17(5):901-910.
• [27]Raper SE, Sarwer DB: Informed consent issues in the conduct of bariatric surgery. Surg Obes Relat Dis 2008, 4(1):60-68.
• [28]Hofmann B: Stuck in the Middle: The Many Moral Challenges With Bariatric Surgery. Am J Bioeth 2010, 10(12):3-11.
• [29]Hofmann B: Ethical aspects of bariatric treatment of adult obesity. In. Institute of Health Economics: Alberta; 2011.
• [30]Saarni SI, Anttila H, Saarni SE, Mustajoki P, Koivukangas V, Ikonen TS, Malmivaara A: Ethical issues of obesity surgery–a health technology assessment. Obes Surg 2011, 21(9):1469-1476.
• [31]Hofmann B: Toward a procedure for integrating moral issues in health technology assessment. Int J Tech Assess Health Care 2005, 21(3):312-318.
• [32]Hofmann B: On value-judgements and ethics in health technology assessment. Poiesis & Praxis 2005, 3(4):277-295.
• [33]Hofmann B: Ethics in Health Technology Assessments (HTA), Volume 28. Oslo: Norwegian Knowledge Center for the Health Services; 2008.
• [34]Kaila M, Mäkelä M: HTA Core Model for Medical and Surgical Interventions. Edited by EUnetHTA. Helsinki: European Network for Health Technology Assessment EUnetHTA; 2008.
• [35]Saarni S, Hofmann B, Lampe K, Luhmann D, Makela M, Velasco-Garrido M, Autti-Ramo I: Ethical analysis to improve decision-making on health technologies. Bull World Health Organ 2008, 86(8):617-623.
• [36]Burls A, Caron L, de Langavant GC, Dondorp W, Harstall C, Pathak-Sen E, Hofmann B: Tackling ethical issues in HTA: a proposed framework. Int J Tech Assess Health Care 2010. in press
• [37]Hofmann B: The encompassing ethics of bariatric surgery. Am J Bioeth w2, 10(12):w1-w2.
• [38]Hofmann B, Haaheim L, Søreide J: Ethics of palliative surgery in patients with cancer. Br J Surg 2005, 92(7):802-809.
• [39]Bluher S, Till H, Kiess W: Bariatric surgery in extremely obese children and adolescents. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2011, 54(5):577-583.
• [40]Levitsky LL, Misra M, Boepple PA, Hoppin AG: Adolescent obesity and bariatric surgery. Curr Opin Endocrinol Diabetes Obes 2009, 16(1):37-44.
• [41]Treadwell JR, Sun F, Schoelles K: Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Ann Surg 2008, 248(5):763-776.
• [42]O'Brien PE, Sawyer SM, Laurie C, Brown WA, Skinner S, Veit F, Paul E, Burton PR, McGrice M, Anderson M: Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA 2010, 303(6):519-526.
• [43]Weiss R: Devices for the treatment of obesity: will understanding the physiology of satiety unravel new targets for intervention? J Diabetes Sci Technol 2008, 2(3):501-508.
• [44]Garcia VF, DeMaria EJ: Adolescent bariatric surgery: treatment delayed, treatment denied, a crisis invited. Obes Surg 2006, 16(1):1-4.
• [45]Capella JF, Capella RF: Bariatric surgery in adolescence. Is this the best age to operate? Obes Surg 2003, 13(6):826-832.
• [46]Dixon J: Bariatric surgery in adolescents: A difficult issue. J Paediatr Child Health 2010, 46(Suppl. 2):3.
• [47]Dixon JB, Jones K, Dixon M: Medical versus surgical interventions for the metabolic complications of obesity in children. Semin Pediatr Surg 2009, 18(3):168-175.
• [48]El-Metainy S, Ghoneim T, Aridae E, Abdel Wahab M: Incidence of perioperative adverse events in obese children undergoing elective general surgery. Br J Anaesth 2011, 106(3):359-363.
• [49]Jarvholm K, Olbers T, Marcus C, Marild S, Gronowitz E, Friberg P, Johnsson P, Flodmark CE: Short-term psychological outcomes in severely obese adolescents after bariatric surgery. Obesity (Silver Spring) 2012, 20(2):318-323.
• [50]Widhalm K, Dietrich S, Prager G, Silberhummer G, Orth D, Kispal ZF: Bariatric surgery in morbidly obese adolescents: a 4-year follow-up of ten patients. Int J Pediatr Obes 2008, 3(Suppl 1):78-82.
• [51]Groven KS, Raheim M, Engelsrud G: "My quality of life is worse compared to my earlier life": living with chronic problems after weight loss surgery. Int J Qual Stud Health Well-being 2010., 5(4) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989899 webcite (Accessed May 3, 2013)
• [52]Zeller MH, Roehrig HR, Modi AC, Daniels SR, Inge TH: Health-related quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics 2006, 117(4):1155-1161.
• [53]King T, Wheeler M, Fernandez A, Schillinger D, Bindman A, Grumbach K, Villela T: Medical Management of Vulnerable & Underserved Patients: Principles, Practice, Population. New York, NY, US: McGraw; 2006.
• [54]Roehrig HR, Xanthakos SA, Sweeney J, Zeller MH, Inge TH: Pregnancy after gastric bypass surgery in adolescents. Obes Surg 2007, 17(7):873-877.
• [55]Ungar W: Health technology assessment in child health. Value Health 2012, 16(4):A206-A207.
• [56]Hell E, Miller K: Bariatric surgery–stereotypes and paradigms. Zentralblatt für. Chirurgie 2002, 127(12):1032-1034.
• [57]Puhl RM, Heuer CA: The stigma of obesity: a review and update. Obesity 2009, 17(5):941-964.
• [58]Ogden J, Clementi C, Aylwin S: The impact of obesity surgery and the paradox of control: a qualiltative study. Psychol Health 2006, 21(2):273-293.
• [59]Holm S: Obesity interventions and ethics. Obes Rev 2007, 8(Suppl 1):207-210.
• [60]Mackenzie R: Don't let them eat cake! A view from across the pond. Am J Bioeth 2010, 10(12):16-18.
• [61]Alderman J, Smith JA, Fried EJ, Daynard RA: Application of law to the childhood obesity epidemic. J Law Med Ethics 2007, 35(1):90-112.
• [62]English A: The health of adolescent girls: does the law support it? Curr Womens Health Rep 2002, 2(6):442-449.
• [63]Caniano DA: Ethical issues in pediatric bariatric surgery. Semin Pediatr Surg 2009, 18(3):186-192.
• [64]Duncan DT: Parental misperception of their child's weight status: Clinical implications for obesity prevention and control. Obesity 2011, 19(12):2293.
• [65]Varness T, Allen DB, Carrel AL, Fost N: Childhood obesity and medical neglect. Pediatrics 2009, 123(1):399-406.
• [66]Weiss R: Bariatric surgery for obese adolescents - 'make assurance doubly sure'. Obes Facts 2009, 2(5):277-280.
• [67]Jamal MK, DeMaria EJ, Johnson JM, Carmody BJ, Wolfe LG, Kellum JM, Meador JG: Insurance-mandatd preoperative dietary counseling does not improve ouotcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity. Surg Obes Relat Dis 2006, 2(2):122-127.
• [68]Sabin J, Fanelli R, Flaherty H, Istfan N, Mariner W, Barnes JN, Pratt JS, Rossi L, Samour P: Best practice guidelines on informed consent for weight loss surgery patients. Obes Res 2005, 13(2):250-253.
• [69]Wee CW, Pratt JS, Fanelli R, Samour PQ, Trainer LS, Paasche-Orlow MK: Updates for informed consent and patient education in weight loss surgery. Obesity 2009, 17:885-888.
• [70]Dorn LD, Susman EJ, Fletcher JC: Informed consent in children and adolescents: age, maturation and psychological state. J Adolesc Health 1995, 16(3):185-190.
• [71]Gallagher SM: What is the meaning of informed consent, weight loss surgery, and the pediatric patient? Bariatric Nursing and Surgical Patient Care 2010, 5(3):231-234.
• [72]Madan AK, Tichansky DS, Taddeucci RJ: Postoperative laparoscopic bariatric surgery patients do not remember potential complications. Obes Surg 2007, 17(7):885-888.
• [73]Reynolds WW, Nelson RM: Risk perception and decision processes underlying informed consent to research participation. Soc Sci Med 2007, 65(10):2105-2115.
• [74]Nichols C, Oermann MH: An evaluation of bariatric web sites for patient education and guidance. Gastroenterol Nurs 2005, 28(2):112-117.
• [75]O'Brien PE: Failure to report financial disclosure information in a study of gastric banding in adolescent obesity. JAMA 2010, 303(23):2357.
• [76]Oakley J, Ashcroft RE, Dawson A, Draper H, McMillan JR: Patients and disclosure of surgical risk. In: Principles of Health Care Ethics. Chichester UK: John Wiley & Sons; 2007.
• [77]James RJ, Morgan JF: Psychiatric needs must be considered. BMJ 2010, 341:c5298.
• [78]van Hout G, van Heck G: Bariatric psychology, psychological aspects of weight loss surgery. Obes Facts 2009, 2(1):10-15.
• [79]Sarwer DB, Cohn NI, Gibbons LM, Magee L, Crerand CE, Raper SE, Rosato EF, Williams NN, Wadden TA: Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004, 14:1148-1156.
• [80]Baldaro B, Rossi N, Caterina R, Codispoti M, Balsamo A, Trombini G: Deficit in the discrimination of nonverbal emotions in children with obesity and their mothers. Int J Obes 2003, 27(2):191-195.
• [81]Berdah C: Obesity and psychiatric disorders. Ann Med Psychol 2010, 168(3):184-190.
• [82]Davison KK, Schmalz DL, Young LM, Birch LL: Overweight girls who internalize fat stereotypes report low psychosocial well-being. Obesity (SilverSpring) 2008, 16(Suppl 2):S30-S38.
• [83]Grubic M: Psychosocial causes and consequences of obesity in children. Paediatria Croatica Suppl 2008, 52(1):57-60.
• [84]Herva A, Laitinen J, Miettunen J, Veijola J, Karvonen JT, Laksy K, Joukamaa M: Obesity and depression: results from the longitudinal Northern Finland 1966 Birth Cohort Study. Int J Obes (Lond) 2006, 30(3):520-527.
• [85]Tadiello P, Salvatoni A, Alberti G, Bosetti G, Gambarini G, Marni E: Obesity and mental disorders in childhood. Pediatria Medica e Chirurgica 1990, 12(6):647-654.
• [86]Wichstrom L: Social, psychological and physical correlates of eating problems. A study of the general adolescent population in Norway. Psychol Med 1995, 25(3):567-579.
• [87]Alejandra B, Roxana VR, Patricia TS, Jaimes-Aviles MG, Cynthia MC, Juan FR, Annarzhvaelig GA: Academic performance in urban schoolchildren with Metabolic Syndrome. FASEB J 2009, 23(Meeting Abstract Supplement):914-918. Conference: Experimental Biology (EB 2009)
• [88]Li Y, Dai Q, Jackson JC, Zhang J: Overweight is associated with decreased cognitive functioning among school-age children and adolescents. Obesity 2008, 16(8):1809-1815.
• [89]Cawley J, Spiess CK: Obesity and skill attainment in early childhood. Econ Hum Biol 2008, 6(3):388-397.
• [90]Dixon JB, Fitzgerald DA, Kow L, Bailey D, Baur LA: Adolescent bariatric surgery: ANZ guidance and recommendations. ANZ J Surg 2011, 81(12):854-855.
• [91]van Hout GC, van Oudheusden I, van Heck GL: Psychological profile of the morbidly obese. Obes Surg 2004, 14:579-588.
• [92]Aibel CE: The influence of weight on sense of self among college women. Dissertation Abstr Int B Sci Eng 2003, 64(4-B):1890.
• [93]Austin SB, Haines J, Veugelers PJ: Body satisfaction and body weight: Gender differences and sociodemographic determinants. BMC Public Health 2009, 9:Article Number: 313.
• [94]Latner JD, Rosewall JK, Simmonds MB: Childhood obesity stigma: association with television, videogame, and magazine exposure. Body Image 2007, 4(2):147-155.
• [95]Latner JD, Schwartz MB: Weight Bias in a Child's World. In Weight bias: Nature, consequences, and remedies. Edited by Brownell KD, Puhl RM, Schwartz MB, Rudd L. New York, NY, US: Guilford Publications; 2005:54-67.
• [96]Vander Wal JS, Mitchell ER: Psychological complications of pediatric obesity. Pediatr Clin North Am 2011, 58(6):1393-1401.
• [97]Grilo CM, Masheb RM, Brody M, Toth C, Burke-Martindale CH, Rothschild BS: Childhood maltreatment in extremely obese male and female bariatric surgery candidates. Obes Res 2005, 13:123-130.
• [98]Hensrud DD, Klein S: Extreme obesity: a new medical crisis in the United States. Mayo Clinical Proceedings 2006, 81(Suppl 10):S5-S10.
• [99]Padwal RS, Sharma AM: Treating severe obesity: morbid weights and morbid waits. CMAJ 2009, 181(11):777-778.
• [100]Edwards VJ, Dube SR, Felitti VJ, Anda RF: It's OK to ask about past abuse. Am Psychol 2007, 62(4):327-328.
• [101]Zimmerman M, Francione-Witt C, Chelminski I, Young D, Boerescu D, Attiullah N, Pohl D, Roye GD, Harrington DT: Presurgical psychiatric evaluations of candidates for bariatric surgery, part 1: reliability and reasons for and frequency of exclusion. J Clin Psychiatry 2007, 68(10):1557-1562.
• [102]White A, O'Brien B, Houlihan T, Darker C, Shea BO: Childhood obesity; parents fail to Recognise. General practitioners fail to act. Ir Med J 2012, 105(1):10-13.
• [103]Levine MD, Ringham RM, Kalarchian MA, Wisniewski L, Marcus MD: Is family-based behavioral weight control appropriate for severe pediatric obesity? Int J Eat Disord 2001, 30:318-328.
• [104]Fallon EM, Tanofsky-Kraff M, Norman AC, McDuffe JR, Taylor ED, Cohen ML, Young-Hyman D, Keil M, Kolotkin RL, Yanovski JA: Health-related quality of life in overweight and nonoverweight black and while adolescents. J Pediatr 2005, 147(443):450.
• [105]Zeller MH, Modi AC: Predictors of health-related quality of life in obese youth. Obesity 2006, 14:122-130.
• [106]Fisher L, Fraser J, Alexander C: Caregivers' inability to identify childhood adiposity: A cross-sectional survey of rural children and their caregivers' attitudes. Aust J Rural Health 2006, 14(2):56-61.
• [107]Pagnini D, King L, Booth S, Wilkenfeld R, Booth M: The weight of opinion on childhood obesity: recognizing complexity and supporting collaborative action. Int J Pediatr Obes 2009, 4(4):233-241.
• [108]Wilde ML: Bioethical and legal implications of pediatric gastric bypass. Willamette Law Review 2004, 40(3):575-625.
• [109]Pomeranz JL: A historical analysis of public health, the law, and stigmatized social groups: the need for both obesity and weight bias legislation. Obesity 2008, 16(Suppl 2):S93-S103.
• [110]Brochu PM, Gawronski B, Esses VM: The integrative prejudice framework and different forms of weight prejudice: An analysis and expansion. Group Processes & Intergroup Relations 2011, 14(3):429-444.
• [111]Puhl R, Brownell KD: Bias, discrimination and obesity. Obes Res 2001, 9(12):788-805.
• [112]Andreyeva T, Puhp R, Brownell KD: Changes in perceived weight discrimination among Americans: 199501996 through 2004-2006. Obesity 2008, 16:1129-1134.
• [113]Brownell KD, Puhl RM, Schewartz MB, Rudd L: Weight bias: nature, consequences, and remedies. New York: The Guilford Press; 2005.
• [114]Ata RN, Thompson JK: Weight bias in the media: A review of recent research. Obes Facts 2010, 3(1):41-46.
• [115]Goldberg C: Citing intolerance, obese people take steps to press cause. In Understanding prejudice and discrimination. Edited by Plous S. New York, NY, US: McGraw-Hill; 2003:93-97.
• [116]Hansson LM, Karnehed N, Tynelius P, Rasmussen F: Prejudice against obesity among 10-year-olds: a nationwide population-based study. Acta Paediatr 2009, 98(7):1176-1182.
• [117]Koroni M, Garagouni-Areou F, Roussi-Vergou CJ, Zafiropoulou M, Piperakis SM: The stigmatization of obesity in children. A survey in Greek elementary schools. Appetite 2009, 52(1):241-244.
• [118]Kraig KA, Keel PK: Weight-based stigmatization in children. Int J Obes 2001, 25(11):1661-1666.
• [119]Margulies AS, Floyd RG, Hojnoski RL: Body size stigmatization: an examination of attitudes of african american preschool-age children attending head start. J Pediatr Psychol 2008, 33(5):487-496.
• [120]Tsai AG, Wadden TA, Pillitteri JL, Sembower MA, Gerlach KK, Kyle TK, Burroughs VJ: Disparities by ethnicity and socioeconomic status in the use of weight loss treatments. J Natl Med Assoc 2009, 101(1):62-70.
• [121]Cowan GS Jr, Hiler ML, Buffington C: Criteria for selection of patients for bariatric surgery. Eur J Gastroenterol Hepatol 1999, 11(2):69-75.
• [122]Greenleaf C, Chambliss H, Rhea DJ, Martin SB, Morrow JR Jr: Weight stereotypes and behavioral intentions toward thin and fat peers among White and Hispanic adolescents. J Adolesc Health 2006, 39(4):546-552.
• [123]Hansson LM, Rasmussen F: Predictors of 10-year-olds' obesity stereotypes: A population-based study. Int J Pediatr Obes 2010, 5(1):25-33.
• [124]Hebl MR, Ruggs EN, Singletary SL, Beal DJ: Perceptions of obesity across the lifespan. Obesity (Silver Spring) 2008, 16(Suppl 2):S46-S52.
• [125]Jimenez-Cruz A, Bacardi-Gascon M, Armendariz-Anguiano A, Marquez IB, Sepulveda-Romo M, Revelles Rojas IC: Mexican physicians' bias towards the obese child. Nutr Hosp 2008, 23(1):77-78.
• [126]King LA, Loss JHM, Wilkenfeld RL, Pagnini DL, Booth ML, Booth SL: Australian GPs' perceptions about child and adolescent overweight and obesity: The weight of opinion study. Br J Gen Pract 2007, 57(535):124-129.
• [127]Thornton W, Dhorajiwala T, Bose-Haider B, Puttha R: Questionnaire survey looking at current practice, satisfaction and barriers faced by primary and secondary care health professionals involved in managing children with obesity. Conference: Royal College of Paediatrics and Child Health Annual Conference, RCPCH 2010 Coventry United Kingdom. Conference Start: 20100420 Conference End: 20100422. Conference Publication:(var.pagings) 2010, A51. [Archives of Disease in Childhood]
• [128]Kaminsky J, Gadaleta D: A study of discrimination within the medical community as viewed by obese patients. Obes Surg 2002, 12(1):14-18.
• [129]Bøgedal G, Plambech L: Etik og kommunikation i behandlingen af svært overvægtige patienter. Ergoterapeuten 2008, 69(9):26-29.
• [130]Cowan GS Jr: What do patients, families and society expect from the bariatric surgeon? Obes Surg 1998, 8(1):77-85.
• [131]Oliver JE: The politics of pathology: how obesity became an epidemic disease. Perspect Biol Med 2006, 49(4):611-627.
• [132]Barry CL, Jarlenski M, Grob R, Schlesinger M, Gollust SE: News Media Framing of Childhood Obesity in the United States From 2000 to 2009. Pediatrics 2011, 128(1):132-145.
• [133]Levitt M: Natural ways are better: adolescents and the "anti-obesity gene. Sci Eng Ethics 1997, 3(3):305-315.
• [134]Lean M, Gruer L, Alberti G, Sattar N: ABC of obesity. Obesity–can we turn the tide? BMJ 2006, 333(7581):1261-1264.
• [135]Webb H: 'I've put weight on cos I've been inactive, cos I've 'ad me knee done': moral work in the obesity clinic. Sociol Health Illn 2009, 31(6):854-871.
• [136]Evans E: Why should obesity be managed? The obese individual's perspective. Int J Obes (Lond) 1999, 23(Suppl 4):S3-S5.
• [137]Iqbal CW, Kumar S, Iqbal AD, Ishitani MB: Perspectives on pediatric bariatric surgery: identifying barriers to referral. Surg Obes Relat Dis 2009, 5(1):88-93.
• [138]Woolford SJ, Clark SJ, Gebremariam A, Davis MM, Freed GL: To cut or not to cut: physicians' perspectives on referring adolescents for bariatric surgery. Obes Surg 2010, 20(7):937-942.
• [139]Ten Have M, De Beaufort ID, Mackenbach JP, Van der Heide A: Ethics and prevention of overweight and obesity: an inventory. Obes Rev 2011, 12(9):669-679.
• [140]Stearns PN: Fat history. Bodies and beauty in the Modern West. New York NY: New York University Press; 1997.
• [141]Schermer M: Genomics, obesity and enhancement: moral issues regarding aesthetics and health. Genomics, Society, and Policy 2012, 4(2):36-52.
• [142]Wickins-Drazilova D, Williams G, Consortium I: The ethics of evaluating obesity intervention studies on children. Int J Obes (Lond) 2011, 35(Suppl1):24-29.
• [143]Hinds HL: Currents in contemporary ethics - Pediatric obesity: Ethical dilemmas in treatment and prevention. J Law Med Ethics 2005, 33(3):599-602.
• [144]Hinds HL: Pediatric obesity: ethical dilemmas in treatment and prevention. J Law Med Ethics 2005, 33(3):599-602.
• [145]Acs ZJ, Lyles A: Obesity, business and public policy. Northampton, MA, US: Edward Elgar Publishing; 2007:267.
• [146]Gilman S: Fat: A cultural history of obesity by Sander Gilman. Cambridge: Polity; 2008.
• [147]Patterson M, Johnston J: Theorizing the obesity epidemic: Health crisis, moral panic and emerging hybrids. Soc Theor Health 2012, 10(3):265-291.
• [148]Aphramor L: Is a weight-centred health framework salutogenic? Some thoughts on unhinging certain dietary ideologies. Soc Theor Health 2005, 3:315-340.
• [149]Campos P: The obesity myth: why American's obsession with weight is hazardous to your health. New York: Gotham Books; 2004.
• [150]Campos P, Saguy A, Ernsberger P, Oliver E, Gaesser G: The epidemiology of overweight and obesity: public health crisis or moral panic. Int J Epidemiol 2006, 35:55-60.
• [151]Gard M, Wright J: The obesity epidemic: science, morality and ideology. London Eng: Routledge; 2005.
• [152]Herndon A: Collateral damage from friendly fire? Race, nationality, class and the "war against obesity". Soc Semiotic 2005, 15(2):127-141.
• [153]Monaghan LF: Big handsome men, bears and others: virtual constructions of "fat male embodiment". Body Soc 2005, 11(2):81-111.
• [154]Monaghan LF: Discussion piece: A critical take on the obesity debate. Soc Theor Health 2005, 3:302-314.
• [155]Throsby K: "How could you let yourself go like that?" Stories of the origins of obesity in accounts of weight loss surgery. Soc Sci Med 2007, 65(8):1561-1571.
• [156]Coveney J: The government of girth. Health Sociol Rev 2008, 17(2):199-213.
• [157]Barry CL, Brescoll VL, Brownell KD, Schlesinger M: Obesity metaphors: how beliefs about the causes of obesity affect support for public policy. Milbank Q 2009, 87(1):7-47.
• [158]Ahmed HM: Obesity, fast food manufacture, and regulation: revisiting opportunities for reform. Food Drug Law J 2009, 64(3):565-575.
• [159]Brownell KD, Warner KE: The perils of ignoring history: Big Tobacco played dirty and millions died. How similar is Big Food? Milbank Q 2009, 87(1):259-294.
• [160]Damman S, Eide WB: The right to food and freedom from obesity. TidsskrNor Laegeforen 2007, 127(17):2263-2265.
• [161]Eichhorn C, Nagel E: Prevention of overweight and obesity–the role of government, the food industry and the individual. Gesundheitswesen 2010, 72(1):10-16.
• [162]Mueller B: Just where does corporate responsibility end and consumer responsibility begin? The case of marketing food to kids around the globe. Int J Advert 2007, 26:4.
• [163]Govea J: Ethical concerns regarding interventions to prevent and control childhood obesity. Prev Chronic Dis 2011, 8(5):A91.
• [164]Salant T, Santry HP: Internet marketing of bariatric surgery: contemporary trends in themedicalization of obesity. Soc Sci Med 2006, 62(10):2445-2457.
• [165]Simonton SZ: Social inequalities in childhood obesity. In Obesity in childhood and adolescence, Volume 1. Edited by Davies HD, Fitzgerald HE. Westport, CT, US: Praeger Publishers/Greenwood Publishing Group; 2008:61-91. [Medical, biological, and social issues]
• [166]Sundblom E, Petzold M, Rasmussen F, Callmer E, Lissner L: Childhood overweight and obesity prevalences levelling off in Stockholm but socioeconomic differences persist. Int J Obes (Lond) 2008, 32(10):1525-1530.
• [167]Wilson DK: New perspectives on health disparities and obesity interventions in youth. J Pediatr Psychol 2009, 34(3):231-244.
• [168]Ogden C, Carroll M, Kit B, Flegal K: Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA 2012, 307(5):483-490.
• [169]Beydoun MA, Wang Y: Socio-demographic disparities in distribution shifts over time in various adiposity measures among American children and adolescents: What changes in prevalence rates could not reveal. Int J Pediatr Obes 2011, 6(1):21-35.
• [170]Calzada PJ, Anderson-Worts P: The obesity epidemic: are minority individuals equally affected? Prim Care Clin Office Pract 2009, 36(2):307-317.
• [171]Dixon B, Pena MM, Taveras EM: Lifecourse approach to racial/ethnic disparities in childhood obesity. Adv Nutr 2012, 3(1):73-82.
• [172]Rossen LM, Schoendorf KC: Measuring health disparities: Trends in racial-ethnic and socioeconomic disparities in obesity among 2- to 18-year old youth in the United States, 2001-2010. Ann Epidemiol 2012, 22(10):698-704.
• [173]Schuster MA, Elliott MN, Kanouse DE, Wallander JL, Tortolero SR, Ratner JA, Klein DJ, Cuccaro PM, Davies SL, Banspach SW: Racial and ethnic health disparities among fifth-graders in three cities. N Engl J Med 2012, 367(8):735-745.
• [174]Saxena S, Ambler G, Cole TJ, Majeed A: Ethnic group differences in overweight and obese children and young people in England: cross sectional survey. Arch Dis Child 2004, 89:30-36.
• [175]Hudson CE: Being overweight and obese: Black children ages 2-5 years. ABNF J 2008, 19(3):89-91.
• [176]Iriart C, Handal AJ, Boursaw B, Rodrigues G: Chronic malnutrition among overweight Hispanic children: Understanding health disparities. J Immigr Minor Health 2011, 13(6):1069-1075.
• [177]Martinson ML, McLanahan S, Brooks-Gunn J: Race/ethnic and nativity disparities in child overweight in the United States and England. Ann Am Acad Pol Soc Sci 2012, 643(1):219-238.
• [178]Blacksher E: Children's health inequalities: ethical and political challenges to seeking social justice. Hastings Cent Rep 2008, 38(4):28-35.
• [179]Flum DR, Khan TV, Dellinger EP: Toward and rational and equiable use of bariatric surgery. JAMA 2007, 298:1442-1444.
• [180]Ethical evaluations of childhood obesity interventions: equity and social justice Public Health Nutr 2012, 15(8A):1557.
• [181]Hsia DS, Fallon SC, Brandt ML: Adolescent bariatric surgery. Arch Pediatr Adolesc Med 2012, 166(8):757-766.
• [182]Shell RE: The hungry gene. The inside story of the obesity industry. New York, NY: Grove; 2002.
• [183]Cox-White B, Connolly P, Hinman L, Keller DR, Ladenson R, Leever M: Extreme Childhood Obesity. Ethics Education Library 2002, 1.
• [184]Garbarino J, Sigman G: A child's right to a healthy environment. New York, NY, US: Springer Science + Business Media; 2010:254.
• [185]Sigman G: A child's right to an environment that prevents obesity: Ethical considerations. In A child's right to a healthy environment. Edited by Garbarino J, Sigman G. New York, NY, US: Springer Science + Business Media; 2010:163-181.
• [186]Greenway J: Childhood obesity: bringing children's rights discourse to public health policy. Community Pract 2008, 81(5):17-21.
• [187]Goodchild S: Doctors: 'Put obese children into care'. In The Independent. June 10 2007;
• [188]Murtagh L, Ludwig DS: State intervention in life-threatening childhood obesity. JAMA 2011, 306(2):206-207.
• [189]Perryman ML: Ethical family interventions for childhood obesity. Prev Chronic Dis 2011, 8(5):A99.
• [190]Siegel RM, Inge TH: Life-threatening childhood obesity and legal intervention. JAMA 2011, 306(16):1763.
• [191]Varness T: Does Pediatric Obesity Indicate Child Neglect? Virtual Mentor 2010, 12(4):263-267.
• [192]Alexander SM, Baur LA, Magnusson R, Tobin B: When does severe childhood obesity become a child protection issue? Med J Aust 2009, 190(3):136-139.
• [193]McGuire A, Zhang J: Personal responsibility among adolescents. Health Aff 2010, 29(7):1418.
• [194]McNaughton D: From the womb to the tomb: Obesity and maternal responsibility. Crit Publ Health 2011, 21(2):179-190.
• [195]Schmidt H: Childhood obesity and parental responsibilities. Hastings Cent Rep 2008, 38(4):3.
• [196]Shrewsbury VA, Steinbeck KS, Torvaldsen S, Baur LA: The role of parents in pre-adolescent and adolescent overweight and obesity treatment: a systematic review of clinical recommendations. Obes Rev 2011, 12(10):759-769.
• [197]Cappelen A, Norheim OF: Responsibility in health care - a liberal egalitarian approach. J Med Ethics 2005, 31:476-480.
• [198]Nicholls SG, Williams D: The parent versus the state: Responsibility in childhood obesity. Conference: 18th European Congress on Obesity, ECO 2011 Istanbul Turkey. Conference Start: 20110525 Conference End: 20110528. Conference Publication:(var.pagings) 2011, 38. [Obesity Reviews]
• [199]Holm S: Parental Responsibility and Obesity in Children. Public Health Ethics 2008, 1(1):21-29.
• [200]Pratt KJ, Greer AG: Debating parental responsibility for childhood obesity: Ethical and legal considerations. Bariatric Nursing and Surgical Patient Care 2012, 7(3):146-149.
• [201]Purcell M: Raising healthy children: Moral and political responsibility for childhood obesity. J Public Health Policy 2010, 31(4):433-446.
• [202]Kersh R, Stroup DF, Taylor WC: Childhood obesity: a framework for policy approaches and ethical considerations. Prev Chronic Dis 2011, 8(5):A93.
• [203]Brownell KD, Kersh R, Ludwig DS, Post RC, Puhl RM, Schwartz MB, Willett WC: Personal responsibility and obesity: a constructive approach to a controversial issue. Health Aff 2010, 29(3):379-387.
• [204]Dietz WH, Bland MG, Gortmaker SL, Molloy M, Schmid TL: Policy tools for the childhood obesity epidemic. J Law Med Ethics 2002, 30(3 Suppl):83-87.
• [205]Phillips MM, Ryan K, Raczynski JM: Public policy versus individual rights in childhood obesity interventions: perspectives from the Arkansas experience with Act 1220 of 2003. Prev Chronic Dis 2011, 8(5):A96.
• [206]van Geelen SM, Bolt LL, van Summeren MJ: Moral aspects of bariatric surgery for obese children and adolescents: the urgent need for empirical-ethical research. Am J Bioethics 2010, 10(12):30-32.
• [207]van Geelen SM, Bolt LL, van Summeren MJ: Moral aspects of bariatric surgery for obese children and adolescents: the urgent need for empirical-ethical research. Am J Bioeth 2010, 10(12):30-32.
• [208]Helmrath MA, Brandt ML, Inge TH: Adolescent Obesity and Bariatric Surgery. Surg Clin North Am 2006, 86(2):441-454.
• [209]Allison DB, Elobeid MA, Cope MB, Brock DW, Faith MS, Vander VS, Berkowitz R, Cutter G, McVie T, Gadde KM: Sample size in obesity trials: patient perspective versus current practice. Medical Decision Making 2010, 30(1):68-75.
• [210]Susman EJ, Dorn LD, Fletcher JC: Participation in biomedical research: the consent process as viewed by children, adolescents, young adults, and physicians. J Pediatr 1992, 121(4):547-552.
• [211]Baker J: Methodological and ethical challenges in evaluations of family-based approaches. Conference: 19th European Congress on Obesity, ECO2012 Lyon France. Conference Start: 20120509 Conference End: 20120512. Conference Publication:(var.pagings) 2012, 10. [Obesity Facts]
• [212]Kopelman LM: Children as research subjects: moral disputes, regulatory guidance, and recent court decisions. Mt Sinai J Med 2006, 73(3):596-604.
• [213]Wickins-Drazilova D, Williams G: Ethical and public policy aspects of childhood obesity: opinions of scientists working on an intervention study. Obes Rev 2010, 11(8):620-626.
• [214]Lowry KW: Obesity. In Dulcan's textbook of child and adolescent psychiatry. Edited by Dulcan MK. Arlington, VA, US: American Psychiatric Publishing, Inc; 2010:383-395.
• [215]Pelletier D: Theoretical considerations related to cutoff points. Food Nutr Bull 2006, 27(4:Suppl:Growth:Standard):Suppl-36.
• [216]Rolland-Cachera M: Childood obesity: current definitions and recommendations for their use. Int J Pediatr Obes 2011, 6(5–6):325-331.
• [217]Horlick M, Hediger ML: Measurement matters. J Pediatr 2010, 156(2):178-179.
• [218]Hofmann B: The technological invention of disease. J Med Eth 2001, 27:10-19.
• [219]Ogden J, Bandara I, Cohen H, Farmer D, Hardie J, Minas H, Moore J, Qureshi S, Walter F, Whitehead MA: General practitioners' and patients' models of obesity: whose problem is it? Patient Educ Couns 2001, 44(3):227-233.
• [220]Ogden J, Flanagan Z: Beliefs about the causes and solutions to obesity: a comparison of GPs and lay people. Patient Educ Counsel 2008, 71(1):72-78.
• [221]Cuttler L, Whittaker JL, Kodish ED: The overweight adolescent: clinical and ethical issues in intensive treatments for pediatric obesity. J Pediatr 2005, 146(4):559-564.
• [222]Kuss CL: Absolving a deadly sin: a medical and legal argument for including obesity as a disability under the Americans with Disabilities Act. J Contemp Health Law Policy 1996, 12(2):563-605.
• [223]Allison DB, Downey M, Atkinson RL, Billington CJ, Bray GA, Eckel RH, Finkelstein EA, Jensen MD, Tremblay A: Obesity as a disease: a white paper on evidence and arguments commissioned by the Council of the Obesity Society. Obesity 2008, 16(6):1161-1177.
• [224]Pinkney J: Big questions remain unanswered. BMJ 2010, 341:c5304.
• [225]Wulkan ML, Durham MM: Obesity in the United States: is there a quick fix? Pros and cons of bariatric surgery from the pediatric perspective. Curr Gastroenterol Rep 2005, 7(6):445-450.
• [226]Crosthwaite J: Moral expertise: a problem in the professional ethics of professional ethicists. Bioethics 1995, 9(5):361-379.
• [227]Steinkamp NL, Gordijn B, ten Have HA: Debating ethical expertise. Kennedy Inst Ethics J 2008, 18(2):173-192.
• [228]Archard D: Why moral philosophers are not and should not be moral experts. Bioethics 2011, 25:119-127.
• [229]Inge TH, Jenkins TM, Zeller M, Dolan L, Daniels SR, Garcia VF, Brandt ML, Bean J, Gamm K, Xanthakos SA: Baseline BMI is a strong predictor of nadir BMI after adolescent gastric bypass. J Pediatr 2010, 156(1):103-108.
• [230]Kral JG: A stitch in time versus a life in misery. Surg Obes Relat Dis 2007, 3(1):2-5.