Childhood Obesity and Parental Responsibilities

In his recent Beveridge lecture, Julian LeGrand highlighted a significant shift in social and public health policy over the past sixty years. In 1948, the task for the new British welfare state was to deal with the five "giants of too little": too little income, work, education, housing, and health care. While there is no reason for complacency, the United Kingdom has made significant progress in these areas. But new giants have emerged: the "giants of too much." Excessive consumption of alcohol, tobacco, and food have significantly affected both population health and health care budgets. In this issue of the Report, Erika Blacksher deals with one of the giants of excess—childhood obesity.

Two central points emerge from Blacksher's clear summary of the evidence. First, childhood obesity has serious short-and long-term consequences, affecting not only children's "current and future health but also their evolving and future liberty as adults." Between 40 and 77 percent remain obese as adults, and poor adulthood health is highly correlated with low socioeconomic status and educational attainment. Second, the social gradient in health means that childhood obesity is not distributed equally across socioeconomic groups. As many as one in three children of socioeconomically disadvantaged groups are obese, with higher levels in particular ethnic groups.

Obesity is on the rise in many countries. A comprehensive study completed in November 2007 by the U.K. government estimated that by 2050, 60 percent of adult men, 50 percent of adult women, and about 25 percent of children under sixteen could be obese. The current figures are 30, 25, and 17 percent, respectively. The disadvantaged would be affected disproportionately by these increases, and the report's central message is that individual action alone will not even slow current trends. Instead, a "whole system approach" is urged, with action at the personal, family, community, and national level, and collaboration among government, science, business, and civil society.¹ A similar theme resonates clearly and loudly from Blacksher's discussion of the factors that contribute to childhood obesity. Her example of the Harlem Children's Zone illustrates helpfully how key elements of a systems approach might be realized in practice.

Blacksher's normative discussion starts from the assumption that there is "a void in social and moral theory related to the family. Long neglected, recent analyses show the family to be both a site of private affiliation and a subject of justice." Blacksher seeks to further theoretical thinking in this area and focuses centrally on issues around parental autonomy, where, against the background of a capability approach, she makes several pertinent observations. She also briefly comments on discussions about parental responsibility and their context of thorny debates around the general role of personal responsibility for health. The point shining through here is that we should stop discussing personal responsibility in a binary fashion; it is not the case that either the social environment is to be blamed for people's health states or individuals themselves. Instead, a "both/and" approach of personal and social responsibility is needed. This requires a marked shift away from blame games and a move toward environmental conditions that can realize people's core capabilities.

Commentators in the United Kingdom have recently been debating whether social services should intervene to help severely obese children. Where parents underfeed their children, they may ultimately be charged with neglect, and children may be removed from homes. But the legal situation for obese children is unclear, and the Nuffield Council on Bioethics' recent public health report called on the government to develop criteria for deciding when intrusive interventions would be appropriate.² It is not clear what guidance Blacksher's approach would give in such cases. Would the capability approach justify drastic interventions? Then again, this point might in fact strengthen her arguments. Removing a harmed child results, typically, in a genuine no-win situation. But approaches such as Blacksher's might, in the long run, prevent such cases altogether. If the appropriate environments are secured, and if parents are treated as "partners—not victims or enemies," then it may indeed be possible "to create a better life for their...