It is now well recognized that the United States is a consumer-driven society. Private consumption comprises a rising fraction of GDP, advertising is proliferating, and consumerism, as an ideology and set of values, is widespread. Not surprisingly, those developments are not confined to adults; they also characterize what some have called “the commercialization of childhood.” Children are more involved than ever in media, celebrity, shopping, brand names, and other consumer practices. At the core of this change is children's growing role as independent consumers. In recent years, children's access to income has risen markedly, and they have gone from being purchasers of cheap plastic goods and a few select food items (e.g., candy) to being a major market for a diverse set of goods and services, including foodstuffs. Unofficial estimates suggest that children aged four to twelve spent a reported $6.1 billion in purchases from their own money in 1989, $23.4 billion in 1997, and $30 billion in 2002, for a total increase of four hundred percent.

Eating behaviors evolve during the first years of life as biological and behavioral processes directed towards meeting requirements for health and growth. For the vast majority of human history, food scarcity has constituted a major threat to survival, and human eating behavior and child feeding practices have evolved in response to this threat. Because infants are born into a wide variety of cultures and cuisines, they come equipped as young omnivores with a set of behavioral predispositions that allow them to learn to accept the foods made available to them. During historical conditions of scarcity, family life and resources were devoted to the procurement and preparation of foods, which are often low in energy, nutrients, and palatability. In sharp contrast, today in non-Third World countries children's eating habits develop under unprecedented conditions of dietary abundance, where palatable, inexpensive, ready-to-eat foods are readily available.

Childhood obesity is a serious problem for increasing numbers of children around the world. According to the International Obesity Task Force, 1 of 10 schoolaged children worldwide is overweight or obese, a number totaling 155 million; of these, 2-3% (30-45 million) are obese. Prevalence is highest in the Americas and Europe, followed by the Near/Middle East, with smaller but growing numbers in the Asia-Pacific and Sub-Saharan regions of the world.

In the United States, which provides the data for much of this report, prevalence continues to rise. The most recent nationally representative data indicate that 33.6% of individuals aged 2-19 years were overweight and 17.1% were at risk for overweight in 2003-2004, compared to 28.2% and 13.9% in 1999-2000, respectively. In this age group, the prevalence of overweight or at risk for overweight was highest among Mexican Americans (56.2%), followed by Non-Hispanic blacks (55.1%) and Non-Hispanic whites (49.8%), and a higher percentage of males were overweight (18.2%) compared to females (16.0%).

Although the obesity epidemic appears to have affected all segments of the U.S. population, its impact on children with special health care needs (SHCN) has received little attention. “Children with special health care needs” is a term used in the U.S. to describe children who come to the attention of health care providers and policy makers because they need different services and supports than other children. Government, at both the federal and state levels, has long felt a particular responsibility for safeguarding the health of children with special needs. The definition “children with special health care needs,” in fact, was developed by a work group established by the U.S. Maternal and Child Health Bureau (MCHB) to assist states in their efforts to develop community systems of services for children with complex medical and behavioral conditions.

After years of near total neglect, the problem of childhood obesity is now in the limelight. Terms like “epidemic,” “crisis,” and “emergency” are used frequently when describing the trend. Progress is defined with strong language (e.g., the need for a “war” on obesity) and fueled by statistics such as the observation that this generation of children will be the first to live shorter lives than their parents. Multi-disciplinary journals such as the Journal of Law, Medicine & Ethics have dedicated symposiums to the issue, and conferences have been convened not only by health professionals but by government agencies, the food industry, and even professionals who market to children. The seriousness of childhood obesity is no longer in doubt, and finally attention has turned to the more complex question – what must be done?

Childhood obesity is a national public health problem. Regardless of gender, race, socioeconomic status, or geographic location, children are “gaining weight to a dangerous degree and at an alarming rate.” Since 1980, the number of overweight children has doubled; among adolescents the number has almost tripled. Today, among children who are more than six years old, about nine million are obese. Many of the factors that contribute to obesity occur at a societal level, prompting the Surgeon General to conclude that preventing obesity is a “community responsibility.”

Childhood obesity is, in many important respects, a result of legal policy. Law shapes the situational and environmental influences that drive both dietary intake and physical activity. Government, public health advocates, and the food industry all use the law to alter these influences in furtherance of their respective goals. Public interest advocates attempt to persuade government and corporations to act in the interest of public health while the industry focuses on profit.

The obesity epidemic among children and adolescents in the United States continues to worsen. The most recent analysis of data from the National Health and Nutrition Examination Survey showed that the prevalence of overweight among children and adolescents – defined as a Body Mass Index (BMI) at or above the 95th percentile on gender-specific BMI-for-age growth charts developed by the Centers for Disease Control and Prevention (CDC) – increased significantly between 1999-2000 and 2003-2004. Over this period, the prevalence of overweight among children and adolescents aged 2-19 increased 23% – from 13.9% to 17.1%. In 2003-2004, 18.8% of children aged 6-11 and 17.4% of adolescents aged 12-19 were overweight. Roughly comparable proportions of each age group were considered to be at risk of becoming overweight (BMI equal to or higher than the 85th percentile and less than the 95th percentile).

Defining “community” from a research perspective is difficult. Communities consist of environmental, social, and geographic components. In addition, race, ethnicity, socio-economic status (SES), and group memberships often play roles in community identity. Barry Wellman and Scot Wortley urge that to truly understand and influence a community, and most certainly to conduct research within communities, one must take into account the varied nature of relationships and networks and how they may work together synergistically to meet the needs of community members. Using the Social Ecological Model, with its delineation of multiple spheres of influence (individual-interpersonal-organizational-community-public policy), community-based research has attempted to reach this understanding. Although dramatic shifts have not yet been realized, many studies suggest improved health behaviors and healthy environments, which indicate a promising future for community intervention work. The discussion that follows reviews the theory and rationale for community-based interventions, the socialecological approach to understanding and studying obesity, and the progress and promise of community interventions.

Mounting evidence documents the extraordinary toll on human health resulting from the consumption of unhealthy food products and physical inactivity. Diseases related to poor nutrition – such as diabetes, heart disease, stroke, and some cancers – are among the leading causes of disability and death in the United States. Poor diet and lack of exercise come second only to tobacco use in actual causes of preventable death in this country. It is estimated that 6% of all adult health care, 7% of Medicare, and 11% of Medicaid expenditures are attributable to obesity. According to the Centers for Disease Control and Prevention, the direct medical cost associated with physical inactivity was nearly $76.6 billion in 2000.

In response to America's growing obesity problem, local policymakers have been looking for legal strategies to adopt in their communities to encourage healthful behaviors. Taking the lead from the successful tobacco control movement, nutrition advocates are seeking strategies to “denormalize” unhealthy behaviors, rather than pursuing education-based approaches that encourage individuals to change their own personal behavior.

Childhood obesity continues to rise in the United States, with now over 17% of children and adolescents considered overweight. Childhood obesity predisposes an entire generation to increased risk of chronic diseases and disabilities and is a severe threat to the economic well-being of the nation. At first thought, the solution to the obesity epidemic may seem simple: encourage people to eat less and exercise more. However, the reality is that behavioral change is difficult to achieve without also considering the interplay of genetics, biological processes, and social and environmental mechanisms. As such, investment in obesity research has been considered an important tool to combat obesity and obesity-related diseases. Childhood obesity research, in particular, has drawn considerable attention, given the lower cost of prevention relative to treatment and the high potential for long-term benefits at a population level.

The 2006 term of the United States Supreme Court is now well underway, and the results of the congressional mid-term elections are in. No doubt, decisions will be handed down and national legislation proposed – perhaps even enacted – that will directly or indirectly affect the physician-patient relationship as well as the profession of medicine itself. Of major concern to physicians, patients, and the lay public is the ongoing, rather contentious debate surrounding both patient access to adequate pain control and what constitutes proper physician conduct in treating patients who are experiencing either chronic or end stage disease pain. Those knowledgeable in palliative medicine maintain that an “epidemic of undertreated pain” now exists, and probably has existed for more than a decade. A significant number of patients experience unnecessary pain and suffering, and this disturbing phenomenon is both an individual patient care problem and a public health concern.

Bioethics, once a four-letter word in the private sector, is now an integral part of the decisionmaking process of biotechnology and pharmaceutical companies. And bioethicists, once confined to the classroom and limited to abstract, philosophical discussions about what is right and wrong in medicine and medical research, now play an important role in the practical implementation of ethical boundaries. Bioethicists increasingly are hired by biomedical companies as consultants to highlight and help resolve complex ethical issues that arise in the companies’ normal business practices. Whether motivated by profit, reputation, or a genuine desire to act morally, these companies are willing to pay bioethicists substantial consultation fees for their “expert” opinions. This fairly recent phenomenon has caused some to be concerned about the potential for bioethicists to encounter conflicts of interests. Specifically, many critics of this new relationship between bioethicists and the private sector “are concerned about the appropriateness of ethicists who should have broader interests, such as concerns about social justice, serving clients whose primary interest is profit-maximizing.”

When making decisions for adults lacking decision-making capacity and having no discernable preferences, widespread support exists for using the Best Interests Standard. For example, the President's Council on Bioethics supports this view in its publication, Taking Care: Ethical Caregiving in Our Aging Society. The President's Council maintains that decision-makers should seek the best available care for incapacitated adults, yet clarifies the best care does not always extend biological life for the longest time and advocates careful attention to comfort care and pain control. Their recommendations for making medical decisions for incapacitated adults match guidelines by American Academy of Pediatrics (AAP) committees and by the U.K’.s Nuffield Council on Bioethics report for making medical decisions for children and infants.

For reasons of consistency, fairness, and compassion, this guidance should be applied to all people lacking decision-making capacity. Uniform guidelines, however, would be incompatible with a policy for infants based on the Child Abuse Prevention and Treatment Act (CAPTA) amendments, widely known as the “Baby Doe” Rules.

Slippery slope arguments appear regularly whenever morally contested social change is proposed. Such arguments assume that all or some consequences which could possibly flow from permitting a particular practice are morally unacceptable.

Thus the legalization of abortion in limited circumstances is asserted to lead down the slippery slope towards abortion on demand and even infanticide; and the legalization of assisted suicide to lead inexorably to the acceptance of voluntary euthanasia and subsequently to the sanctioning of the practice of nonvoluntary euthanasia – even involuntary euthanasia of “undesirable” individuals.