Childhood Obesity: Nursing, Ethical, and Legal Considerations

Introduction

Childhood obesity is quickly manifesting itself as one of the predominant health concerns of the decade. If childhood obesity remains on the exponential growth trajectory it currently holds, it will almost inevitably become an epidemic within the United States. The issue has received such public attention that former First Lady Michelle Obama embarked upon a national campaign to increase the healthy choices available to children at school lunch counters and implored children to engage in increased levels of physical activity.

According to the Centers for Disease Control and Prevention (CDC), a child is considered obese if they are above the 95th percentile of the Body Mass Index (Berkowitz, 2009). Children are considered at risk of becoming overweight if they fall above the 85th percentile but below the 95th percentile for BMI (Berkowitz, 2009). The statistical trends paint a troubling picture. Teenagers who are overweight face an 80% probability of becoming obese as they enter early adulthood (Berkowitz, 2009). Even among younger children, those who are four years old face a 20% probability of progressing into adulthood with obesity.

Childhood obesity has become a prominent topic among politicians and lawmakers. There have been persistent calls to regulate the foods offered in vending machines near schools and to limit sugar content in certain products. Some states, such as New York, have instituted taxes on certain foods to discourage consumption of items high in sugar and fat — two components that contribute directly to the persistent problem of childhood obesity.

The premise of this analysis is to examine the main issues surrounding childhood obesity. Nursing considerations are plentiful when analyzing this condition, and this paper discusses those considerations as they relate to nursing practice. Furthermore, there are ethical, moral, and legal issues surrounding childhood obesity, each of which is analyzed within the overall context of the condition.

Cultural Influences and Nursing Considerations

Several researchers have described differing cultural views as a central factor in shaping perceptions of childhood obesity (Crawford, 2004). According to some cultures — specifically within the Hispanic/Latino community — there is a general attitude that weight and health are not significantly correlated. Consequently, Hispanic/Latino children have a statistically significant probability of being overweight. This cultural attitude is confirmed by a study conducted at the outset of the decade: a study of over 200 Hispanic children revealed that 35% of parents did not view their child as obese (Myers & Vargas, 2000).

Minority children show higher rates of increase compared to white children. According to a recent study, African American and Hispanic children experienced an increase in obesity prevalence of 10%, compared with an increase of less than 1% among white children — lending strong evidence to the premise that certain demographic groups carry higher rates of obesity (Thorpe, 2004).

Nurses are at the front lines of the struggle against childhood obesity. However, nurses cannot fight this battle alone. They must take critical steps in addressing childhood obesity, including engaging in community awareness and outreach programs tailored to the appropriate social and cultural groups (Garcia, 2006). Nurses working in community health care are best positioned to introduce parents and children to these outreach programs. To do so effectively, nurses must possess strong advocacy and leadership skills.

Nurses must find ways to expand their abilities to enhance advocacy skills at the national, state, and local levels. Although many nurses have readily accepted this provider-advocate role, some question the viability and appropriateness of nurses engaging in such advocacy practices. A study conducted by Gebbin et al. (2000) found that the majority of nurses view effective community outreach as a natural extension of their professional role.

Concomitant with a nurse-practitioner's capacity for effective outreach is the leadership skill necessary to ensure that those who need information actually receive it (Berkowitz, 2009). Collaborative leadership, as described by Chrislip (1996), involves a shared leadership model. In order to effectively address childhood obesity, the nurse must establish a rapport with the community — one that involves developing a deep sense of trust, insight, and a meaningful understanding of human behavior and power dynamics (Berkowitz & Nicola, 2003).

Each of these nursing considerations assists nurses in working with parents and community organizers to address childhood obesity. In addition to these considerations, various ethical, moral, and legal implications factor into the issue. These nursing considerations should not be examined in isolation, but rather in conjunction with the broader issues surrounding childhood obesity.

Ethical Issues in Pediatric Obesity Treatment

The advent of childhood obesity has led to the development of various treatment modes designed to alleviate the condition in children. One treatment that has become increasingly popular is bariatric surgery in children (Taylor, 2009). Several ethical issues present themselves when considering this type of surgery in pediatric patients. One is the controversy over the best time to surgically intervene in cases of pediatric obesity. The optimal timing depends on the magnitude of the patient's obesity-related conditions (Taylor, 2009). A natural concern arising from pediatric bariatric surgery is that the procedure may compromise growth and development in children who undergo it at a relatively young age.

During adolescent development there is a rapid increase in neuromuscular and skeletal development. Bariatric surgery requires that the patient be both physiologically and psychologically prepared. Although bariatric patients may be physically and physiologically ready for surgery, many are not psychologically prepared — which generates an ethical debate as to whether such invasive surgery is truly in the patient's best interest (Taylor, 2009). When the patient is a minor, this decision becomes the parents' responsibility, and the ethical considerations consequently fall on them.

This dilemma leads to the discussion of informed consent. Many ethicists consider the age range of 8 to 14 appropriate for patient consent in significant physical treatments; however, bariatric surgery is generally reserved for older children and adolescents. Furthermore, it is considered ethically correct to require all decision-makers to reach a consensus on treatment (Taylor, 2009).

Another ethical consideration involves distributive justice — specifically, the likelihood that insurance companies may cease to offer or may deny coverage for obesity-related conditions. Recent changes to health care law have made it illegal for insurance companies to drop patients due to pre-existing conditions. Additionally, limited ability to pay may exacerbate existing disparities in the sociodemographic makeup of the obese population. Socioeconomic factors are likely to exert a profound influence on health, though there are conflicting views on their direct link to childhood obesity. Data on household socioeconomic factors are often limited to self-reported parental education and income levels (Anderson, 2003). Poverty percentages and poverty-to-income ratios have also been used to stratify survey participants, yet these indexes fail to fully convey the complexities of socioeconomic factors and social class.

One definition of social stratification is the unequal distribution of privileges among population subgroups. A focus on current incomes can mask underlying disparities in material resources such as property and accumulated wealth (Caprio, 2009). Access to resources and services may not be equivalent for a given level of education or income (Anderson, 2003). Neighborhood of residence may influence access to healthy foods, opportunities for physical activity, the quality of local schools, time allocation, and commuting time (Anderson, 2003).

In conjunction with post-operative ethical considerations, there is also the need for certain medications to be prescribed to children who have undergone bariatric surgery. Female patients are commonly placed on contraceptives following the procedure. Parents may find this objectionable, as it could be perceived as sanctioning sexual activity in young patients. This presents a tension between parents seeking to protect their children from societal influences and medical professionals who require certain medications to ease the post-surgical transition.

Bariatric surgery encompasses a broad range of surgical subtypes. Related to this is the ethical question of which subtype is most appropriate. Gastric bypass is the most common form of bariatric surgery; however, it is entirely irreversible (Taylor, 2009). As a result, there is an increased risk of chronic malabsorption in the pediatric obesity population. These ethical considerations lead naturally into a discussion of the legal aspects of childhood obesity.

Conclusion

Childhood obesity is quickly becoming a national problem within the United States. As obesity increases, so too do the ancillary health concerns that develop as a result of the condition. An individual who develops obesity is at higher risk than non-obese individuals for developing diabetes, heart disease, hypertension, and orthopedic problems. In response to this growing epidemic, politicians, community organizers, and other officials have placed the elimination of childhood obesity near the top of the domestic policy agenda. As noted in the introduction, former First Lady Michelle Obama initiated a "Get Fit" program designed to reduce the incidence of childhood obesity. As childhood obesity increases, there is a concomitant rise in related health concerns. If childhood obesity is reduced, there will be a similar decline in the rate of associated health conditions.

Beyond the numerous physical consequences of obesity, there are significant nursing, legal, moral, and ethical issues surrounding the condition. Regarding nursing considerations, patient advocacy has become a focal point for nurses dealing with childhood obesity. For nurses to become effective advocates, there must be a corresponding increase in training to enhance advocacy skills within community outreach programs. Strengthening these skills will ensure that nurses develop the appropriate competencies to effectively convey the information most useful in treating childhood obesity. Nurses must therefore become accustomed to advocating for expanded programs addressing childhood obesity at the national, state, and local levels. Leadership development is central to building the communication abilities required to treat childhood obesity effectively.

In addition to nursing considerations, there are numerous ethical constraints. Foremost is the issue of informed consent. Although many practitioners consider ages 8 to 14 acceptable for informed consent, the trend in recent years is to require all decision-makers to arrive at a unanimous consensus on treatment. An ethical debate also persists as to whether a severe physical intervention such as bariatric surgery is appropriate at a young age, given that young patients may not be psychologically prepared for such a procedure. Children with obesity who seek surgery may also encounter difficulty obtaining insurance coverage, as some insurers do not treat obesity as an insurable condition.

Childhood obesity is not only a health concern but also a drain on social and healthcare services within society. Individuals who suffer from obesity require medical treatment not only for the condition itself but for any secondary complications. An economic model demonstrates why obesity is on the rise: the relative decline in the "cost" of calories compared to the increasing perceived "cost" of exercise helps explain the growth of obesity. Those who suffer from obesity spend upward of $50 billion dollars per year on prescription and over-the-counter medications in an effort to manage their weight.

All of these considerations contribute to the ever-growing conversation surrounding the rising incidence rates of childhood obesity. The nursing, ethical, legal, and economic impacts of obesity will continue until there are significant societal shifts in attitudes and behaviors.