Childhood Obesity and Nutrition
Abstract Schools may have an ethical obligation to help in the prevention of the increasing propensity toward childhood obesity. School programs can be implemented to improve the nutritional quality of students’ diets. Students spend approximately one third of their day in school and consume one to two meals there per day, therefore justifying the importance of the responsibility to advise dietary behaviors and influence healthy decisions.
In consideration of these logical methods, the ethical dilemma arises as good actions conflict with those that may be seen as a conflict of interest by interfering with the choices of children and their parents, faculty, and the community. Childhood obesity is a serious medical condition that affects millions of children and adolescents. This disease is a growing public health concern that must be addressed at the prevention level as opposed to the treatment level, as healthcare has traditionally held its focus.
The costs associated with this epidemic continue to rise to astounding levels. These costs are not only monetary, but more importantly, they are the costs associated with the loss of the ability to live a healthy life. While treatment is undeniably important in taking care of our nation, efforts must be made at multiple levels to prevent the problems our country is going to continue to see if we do not. Schools have a responsibility to protect a student’s well being and to implement policies that will benefit the student and the community in which the student lives.
Implementation of these policies can be a challenge as decision makers and supporters have opposing opinions and raises ethical concerns. The idea behind schools is more than teaching students academically, it also includes a responsibility to support student health, both physically and emotionally. Nutritional health and well being has long been taught and known to support academic performance. It is also known that students who are well nourished are more likely to retain information and less likely to miss school due to sickness.
Research has proven that children from low income families perform better on standardized tests if they participate in the schools breakfast program. These students also have higher attendance than those who do not participate in the school breakfast program. School implementation around healthy diets and exercise will support the greater community in the long term by preventing health related financial costs associated with health problems that largely affect those who are overweight, in addition to the short term costs that may result from childhood disease developed as a result of childhood obesity.
Emphasizing and providing healthy meals, supporting exercise, and education in the schools is important to learning and productivity and short and long term disease prevention. It must be challenged if it is the ethical obligation of the schools to provide children with these tools and resources to make smart decisions or if this challenges the choice of children and their parents, faculty, or even the food and beverage industry who markets specifically to children.
This paper will present research for justifying the need for regulation of foods provided in schools in order to address the existing epidemic and further prevent childhood obesity. The increasing number of obese children and youth in the United States has led policy makers to rank it as a critical public health threat. In 2004, there was a research report written about a study that lasted from 1999 to 2002 entitled “Prevalence of overweight and obesity among children and adolescents: United States” conducted by the Centers for Disease Control.
According to that report 16% of children 6-19 years olds are overweight or obese. This is three times what it was in 1980. This report also discovered than an additional 15% were at risk of becoming overweight (Ogden et al, 2010). Not only has this number tripled, but in the past three decades (according to this same study) obesity has more than doubled in both children and adolescents from ages 2-5 and also ages 12-19 while more than tripling in children between the ages of 6-11 (Hadley et al, 2004). Childhood obesity leads to increased risks to physical and emotional health.
According to the CDC, one in three American children born in 2000 will develop type 2 diabetes (Seibel, 2008). Young people are also at risk of developing serious psychosocial burdens due to societal stigmatization associated with obesity. Between 2001 and 2005, the hospital costs for obese children increased from $125. 9 million to $237. 6 million, according to a study that tracked trends in childhood obesity on hospital care and costs. Researchers also identified a near-doubling in hospitalizations of youth aged 2 to 19 with a diagnosis of obesity between 1999 and 2005 – from 21,743 to 42,429 (Trasande, 2009).
When people eat more calories than they burn off, their bodies store the extra calories as fat. A couple of extra pounds of fat is not a big deal for many people, however, if people keep up the pattern of eating more than they are burning off over time, more and more fat builds up in their bodies. Eventually, the body is holding so much extra fat that the excess fat may cause serious health problems. Factors that increase a child’s risk of becoming overweight include diet, inactivity, genetics, psychological factors, family factors, and socioeconomic factors.
Regular consumption of high-calorie foods, such as fast foods, baked goods and vending machine snacks, contribute to weight gain. High-fat foods are dense in calories. Loading up on soft drinks, candy and desserts also can cause weight gain. Foods and beverages like these are high in sugar and calories. These foods are often served in cafeterias and are considered competitive foods as they “compete” with healthy options available to students. Inactive kids are more likely to gain weight because they do not burn calories through physical activity.
Inactive leisure activities, such as watching television or playing video games, contribute to the problem. If a child comes from a family of overweight people, he or she may be genetically predisposed to gaining weight, especially in an environment where high calorie food is always available and physical activity is not encouraged. Some children may overeat as a way of dealing with problems or emotions, such as stress or boredom. Their parents may have similar tendencies. Kids cannot be blamed for liking sweet, salty and fatty foods because they do taste good.
Since most children do not shop for the family’s groceries and the parents do, they can control their children’s access to these foods by putting healthy foods in the kitchen at home and leaving unhealthy foods in the store. Children from low income backgrounds are at greater risk of becoming obese. Poverty and obesity often go hand in hand because low income parents may not have the time and resources to make healthy eating and exercise a family priority. Obesity affects both body and mind. Extra weight puts stress on the body, especially the bones and joints of the legs.
As a child gets older, kids and teens that are overweight are more likely to develop diabetes and heart disease. The health problems that affect overweight children and teens include Blount’s disease, arthritis, slipped capital femoral epiphyses (SCFE), asthma, sleep apnea, high blood pressure, high cholesterol, gallstones, fatty liver, polycystic ovary syndrome (PCOS) and insulin resistance and diabetes. Blount’s disease is a bone deformity of the lower legs, caused by excess weight on growing bones.
Arthritis is a painful joint problem that may be developed in part to wear and tear on the joints from carrying extra weight. Asthma may be obesity related and results in difficulty breathing, making it harder to keep up with friends, play sports, or just walk from class to class. Sleep apnea is a condition where a person temporarily stops breathing during sleep and is a serious problem for many overweight kids. Not only does it interrupt sleep, but can leave people feeling tired and affect their ability to concentrate and learn. It may also lead to heart problems.
High blood pressure results in the heart having to pump harder and the arteries must carry blood that is moving under greater pressure. If the problem continues for a long time, the heart and arteries may no longer work as well as they should. Although high blood pressure is rare in most teens, it is more common in overweight or obese teens. Abnormal blood lipid levels, including high cholesterol, low HDL, or “good” cholesterol, and high triglyceride levels will increase the risk of heart attack and stroke when a person gets older.
Gallstones are an accumulation of bile that hardens in the gallbladder and may be painful and require surgery. Fatty liver is when fat accumulates in the liver, causing inflammation, scarring, and permanent liver damage. Pseudotumor cerebri is rare, however, causes severe headaches in obese teens. There is no tumor, but pressure builds in the brain. In addition to the headaches, symptoms may include vomiting, and unsteady way of walking, and vision problems that may become permanent if not treated. Polycystic ovary syndrome is where girls who are overweight either miss their periods or do not get them at all.
They may have elevated levels of testosterone levels in the blood. Although it is normal to have some testosterone in their blood, too much can interfere with normal ovulation and may cause excess hair growth, worsening acne, and male type baldness. PCOS is associated with insulin resistance, a sign of possibly developing type 2 diabetes. Insulin resistance and diabetes are developed when insulin becomes less effective at getting glucose into cells as a result of excess body fat. More insulin is then needed to maintain a normal blood sugar.
For some overweight teens, insulin resistance may develop into diabetes (high blood sugar). Children may also experience social and emotional problems. Children often tease or bully their overweight peers, who then may suffer a loss of self-esteem and an increased risk of depression as a result. Overweight children tend to have more anxiety and poorer social skills than normal weight children. At one extreme, these problems may lead to acting out and disruption the classroom. At the other end, they may cause social withdrawal.
Stress and anxiety also interfere with learning by negatively affecting academic performance. Social isolation and low self-esteem can create overwhelming feelings of hopelessness in some overweight children. When children lose hope that their lives will improve, they are well on their way to depression. A depressed child may lose interest in normal activities, sleep more than usual or cry a lot. Some depressed children hide their sadness and appear emotionally flat instead. Either way, depression is as serious in children as it is in adults.
I believe that schools are one of the primary locations for reaching children and youth. Both inside and outside of the classroom, schools present opportunities for students to learn about healthful eating habits and regular physical activity, engage in physical education, and make food and physical activity choices during school meal times and through school related activities. Because children consume so many of their daily calories in schools, the school is the logical place to focus efforts in prevention of obesity through healthy eating. Currently, schools have competing focuses.
One is the federally regulated National School Lunch and Breakfast programs and the other is the competitive foods market where profits in an open market are the main focus. Competitive foods are those that are sold as snacks in the lunchroom, in vending machines on school grounds, and refreshments offered for sale at school activities. They are typically high in calories and lack nutritional quality and health benefits. 55% of high school students and 44% of middle school students eat these unhealthy foods at school and often in place of meals (Fox et al, 2009).
Currently, only minimal federal standards exist for the sale of competitive foods in schools. Unfortunately, many schools are on limited budgets which make providing healthy choices difficult. To generate funds needed to function, school food services often sell the competitive foods because they are able to make a profit on these items. However, data shows that limiting these food offerings may increase meal consumption and actually increasing profits for schools and vendors rather than reducing profits as feared by school administrators (Woodward-Lopez et al, 2010).
Promoting meals offered at schools and increasing the likelihood of buying by students can be crucial to efforts made in schools to reduce and prevent obesity, further benefiting not only the children, but the schools as well. Many schools around the country have reduced the commitment to provide students with healthy food options. One is in part to the budget cuts schools experience. Lack of state and federal funding force administrators to cut where they see appropriate with the goal of providing students with the maximize options under limited resources.
Another reason is that many do not support the importance of prevention at the school levels and neglect the bigger picture that we are feeding our youth to become participating members in our communities. Those who do not support regulation within the schools argue that children have the right to choose the food they eat. On the flip side, schools are regulated in many areas including student coursework and activities where student’s and parents’ opinions are not taken into consideration.
The argument that a child has the right to choose foods of poor nutritional quality at school conflicts with the societal value of child protection. A child’s right to fleeing obesity is among the 54 binding standards and obligations of the 1989 United Nations Convention on the Rights of the Child (UNICEF). Beachamp and Childress’s four foundation principles of biomedical ethics (Kleinman et al, 1998) can help support the question of whether a policy should be in place in schools to provide healthy foods to children in school meets the standards to justify regulatory action.
The four principles are autonomy, beneficence, nonmaleficence, and justice. Autonomy addresses the conflict between school nutrition regulations as an intervention of childhood obesity and the individual right to choose what one eats. So who is responsible for what a child eats? Is it the child, the parents, the schools, the community, or government agencies? Because children do not have the full knowledge of the nutritional values of the foods they eat, parents and schools can provide foods that meet optimal nutrition and the child can then choose from those options.
Both can offer healthy options as opposed to those that may be harmful to a child’s health and development. Healthy school meals are often in competition where unhealthy snacks and sugary drinks are offered in the cafeterias. This negates the goal of regulation. Instead, by offering healthy snack options that will not compete with healthy meals will ensure that students are making healthy choices. In addition, serving healthy foods in schools may carry to the home where students may continue to eat healthy food and also serve as an example to those at home by promoting healthy diets.
The National School Lunch Program stated, “The educational features of a properly chosen diet served at school should not be under-emphasized. Not only is the child taught what a good diet consists of, but his parents and family likewise are indirectly instructed” (Pikoff, 2009). The principle that intervention should not inflict harm is known as nonmaleficence. Regulating healthy food options is not viewed as inflicting harm, however, offering food lacking in nutritional quality could be viewed an inflicting harm on children.
Schools and vendors profit from the sale of unhealthy foods and it can be reversed by educating students to not choose those foods over the healthy options. Kids will not go hungry but it is still argued by many that they will not eat foods that are of a higher nutritional quality. In the argument for providing healthy choices, students will have multiple options to choose from or they can bring their lunches from home. Students have even reported a preference for healthy, fresh food choices over other snack foods (Gosliner et al, 2011).
Social justice is a principle of supporting that people are treated fairly with an equal distribution of good and bad. Social and economic inequalities will be consistent with just principles and will support to maximize benefits for the least advantaged (Rawls, 1971). Schools are one place that is able to provide many opportunities to disadvantaged students so they break through the barriers to become contributing healthy citizens. It is argued that it is unethical to advertise unhealthy foods and drinks at schools and affiliated functions where children are at greater health risk.
Healthy eating may help support a child’s development where they already experience greater psychosocial stresses. While all children will benefit from regulated healthy food offerings at school, those from disadvantaged background may benefit most. Sales and profits of unhealthy foods to vulnerable children can be considered unethical and an example of nonmaleficence, where harm is intentionally inflicted on children. Society’s ethical obligation to reduce harm to children is threatened by schools and vendors who provide foods lacking nutritional value in order to maximize profits.
Consequently, children suffer as they are vulnerable. Regulating school meals optimizes nutrition and helps to prevent childhood obesity. In addition to prevention benefits, healthy eating optimizes academic performance and cognitive reasoning (Center on Hunger, Poverty, and Nutrition Policy 1995). Many regulations have been well received regarding healthy meals, classroom education, and physical education. However, they have not been implemented to full potential in all schools to have a significant impact on decreasing and preventing childhood obesity.
In 2005, California was the first state to limit competitive foods and beverages in schools. The school was effective in implementing the state legislation by limiting unhealthy snacks and beverages and replacing with foods that meet the guidelines as mandated by legislation. Examples of this substitution included replacing sodas with sports drinks, chips with baked versions, and crackers with reduced fat varieties. Although the changes met the legislation’s mandates, it did not make a big difference in offering nutrient rich foods such as fruits, vegetables, and whole grains.
New regulations were implemented and varied from state to state. As a result, Congress and the USDA have been encouraged to examine the quality of foods being offered in schools. In December 2010, the Healthy, Hunger-Free Kids act of 2010 was passed as a law. This act requires the Secretary of Agriculture to establish science-based nutrition standards within a year. All food and drinks offered outside breakfast and lunches at schools had to meet these standards. Whether these standards were met within a year as required and met the recommendations set by the Institute of Medicine is unknown (Pub L No. 11-296, 124 Stat 3183, 2010). Improvements to the National School Lunch and School Breakfast programs were improved as a result of the Healthy, Hunger-Free Kids act as it enforced schools offer meals that meet dietary recommendations as outlined in federal Dietary Guidelines for Americans. Part of these standards include more offerings of nutrient rich foods such as fruits, vegetables, and whole grains, and limiting foods high in fats, sugars, and salt. Large strides will be made if these policies are implemented.
The major challenge of this will be effectively limited unhealthy foods across the board and finding the money to spend on the more nutritious foods during economic cuts. These challenges will slow or limit the goal of the programs in promoting health and decreasing and preventing childhood obesity. A prime example of how these goals are limited is through the privatization of school nutrition programs, about a quarter being outsourced to large food service management companies such as Aramark and Sodexo. The Agriculture Department pays for a portion of the healthy foods for schools, including fresh fruit, potatoes, and lean meats.
The school then has the choice to cook these foods or to sent to processors to make these foods into chicken nuggets and pizza for example. These processed foods have about the same nutritional quality and unhealthy snacks such as chips. Sodexo claims they support “nutrition education to encourage young students to eat more fruits and vegetables” (Komisar, 2011) yet they are giving rebates to the schools for contracts to process their foods. Many administrators are choosing profit driven menus as opposed to purchasing locally and investing in our nation’s future of health.
Interventions are needed to support regulation in schools by providing evidence of the importance of schools’ effects in providing healthy meals. It is a school’s responsibility with support of educators, parents, community members, and government agencies to provide an environment that promotes education and health. Regulations should limit unhealthy competitive foods and offer healthy alternatives that do not contribute to empty calories and rather provide nutritional values in accordance with the Dietary Guidelines for Americans. Regulation is in the best interest of a child’s health and further developing into a contributing itizen of the community and decreasing associated long term medical costs. As stated by the precautionary principle, “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically” (Wingspread Conference on the Precautionary Principle, 1998). In other words, society has a moral duty to protect the public from exposure to harm where research has shown risk. Decreased learning abilities as a result of poor health and nutrition are well documented.
Other studies show that academic performance is improved, especially in students from disadvantaged families, as a result of better nutrition and increased physical activity (Hollar et al, 2010). A healthy diet may close the gap in learning disparities in disadvantaged students. Students from this background will benefit most from ongoing access to nutritious foods. A child’s future may also be compromised if obese or have poor nutrition and the nation will be burdened with increased medical costs. It is well documented that these deficiencies may contribute to heart disease, diabetes, osteoporosis and other linked health problems.
There is no ethical justification for the promotion of unhealthy diets to school-aged children. A child’s best interest demands the support and resources to address the issues of obesity and to take prevention measures in schools by supporting and implementing regulation. Until recently, efforts had focused largely on the treatment of obesity rather than prevention. Reversing the rapid rise in obesity among American children and youth will require a broad based approach involving multiple partners and tough choices and trade-offs at various levels.
Given the intertwining nature of the issue, prevention efforts need to be coordinated at the highest federal levels. In addition to federal contributions, state and local governments should take on a leadership role by raising childhood obesity prevention to a top priority and making continued commitments to support policies and programs that match the scale at which the problem now exists. Just as broad based approaches have been used to address other public health concerns, including automobile safety and tobacco use, obesity prevention should be public health in action at its broadest and most nclusive level. Prevention of obesity in children and youth should be and can be a national public health priority. Since the 1930s, the federal government has had commitments to programs that address nutritional deficiencies and encourage physical fitness, but only recently has obesity been targeted specifically. In Healthy People 2010, the health objectives for the nation, the U. S. Department of Health and Human Services (HHS) set a goal of reducing the proportion of children and youth who are obese by five percent by 2010 (Healthy People 2010).
Only through policies, legislation, programs, and research will significant changes be made. The officers of HHS are in the best position to organize a high level task force involving other federal agencies to coordinate research programs, policies, and budgets aimed at reducing childhood obesity and to encourage the interdepartmental teamwork needed to resolve such a complex issue. Congressional support will be crucial to ensuring that funding is made available for the research that is needed to further clarify the causes of childhood obesity and to identify the best measures to prevent it.
For example, expansion of the total funding for the state grant programs available through the Centers for Disease Control and Prevention could lead to needed resources being allocated to support more states, particularly those with the highest prevalence of childhood obesity. Congressional support also is key to moving forward efforts that need legislative authorization, such as setting nutritional standards for all foods and beverages available in schools. State and local governments are in the best position to focus on the specific needs of their state, cities, and neighborhoods.
Many of the issues involved in preventing childhood obesity – including actions on street and neighborhood design, plans for parks and community recreational facilities, and location of new schools and retail food facilities – require decisions by county, city, or town officials. States should increase funding for their public health agencies so that they can more fully follow through on launching obesity prevention efforts. Governments at all levels should coordinate national efforts with state and community efforts and engage community organizations and the private sector in developing new approaches to promoting healthy weight.
Rigorous evaluation of obesity prevention interventions is essential. Only through careful evaluation can prevention interventions be refined; those that are unsuccessful can be discontinued or refocused, and those that are successful can be identified, replicated, and disseminated. The federal investment in research focused on childhood obesity must be strengthened in order to do this. The obesity epidemic is a serious public health problem that calls for immediate action to reduce its prevalence as well as its health and social consequences.