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Obesity is a global condition affecting both adults and children. Mothers play an important role in identifying problems with their child's weight. However, studies are limited on the accuracy of maternal perceptions of her child's weight status in early childhood. The aim of this study was to look at maternal perceptions of her child's weight status in 5-year-old children and to investigate factors influencing this.
Materials and Methods
339 mother and child pairs were followed up from the ROLO Kids study in the National Maternity Hospital, Dublin, Ireland. Height and weight of the mother and the child were measured, and BMI was calculated. Demographic details were collected and questionnaires asked mothers to assign their child to a weight category and to give the reason they put their child in this particular category. KAPPA analysis and student t tests were used to analyse the data.
In this cohort over 75% of the children were normal weight, 14.7% were in the overweight category, and 8.5% in the obese category. The KAPPA score for maternal-perceived category and actual weight status was 0.037 which is a low level of agreement. Mothers were more likely to underestimate their child's weight, with 28.5% underestimating the appropriate weight category for their child compared with 2.4% who overestimated. Maternal age, education, and child sex did not influence accurate weight assessments; however, mothers with a higher BMI were more likely to inaccurately assess their child's weight (P < 0.05).
Maternal perception of their child's weight status is not an accurate indication of child weight, particularly for mothers with a raised BMI. This research highlights the important role of health care providers in assessing child weight status, rather than relying on parental reports alone, in order to appropriately intervene to reduce the incidence of childhood obesity.
The early fetal environment during pregnancy is extremely important and research indicates that weight at birth can have crucial impacts for the individual's health later in life. With rates of childhood obesity estimated to be as high as 21% in some European countries, it is vital that early risk factors are identified so that interventions can be developed. We aimed to investigate if children born macrosomic (birth weight > 4kg) remained larger than normal birth weight babies up to 5 years of age.
Materials and Methods:
This is a longitudinal follow-up of 387 five-year-old children (53% born with macrosomia, 47% normal birth weight) born into the ROLO randomised control trial in the National Maternity Hospital, Dublin (ISRCTN54392969). Birth weight was previously recorded then at 6 months, 2 years, and 5 years of age child height, weight, anthropometric and skinfold measurements were collected. Body Mass Index (kg/m2) and centiles were calculated. Student t-tests and Mann-Whitney U tests were used to compare the two groups with multiple linear regression modelling to control for confounders.
Children with a birth weight > 4 kg had consistently higher weights, lengths, and BMI centiles, along with increased head and chest circumferences, compared to normal birth weight children from 6 months up to 5 years of age (p < 0.05). After controlling for child sex, intervention group, smoking during pregnancy, maternal education status, and maternal BMI, children with macrosomia were 0.61 kg heavier than non-macrosomic infants at 5 years of age (95% CI: 0.04–1.18, p < 0.05).
Children born with a high birth weight remain heavier and larger into childhood. These individuals are at a higher risk of obesity which highlights the need for monitoring and potential interventions, both during pregnancy and in infancy, to curb the current childhood obesity crisis.
Infant protein intake has been associated with child growth, however, research on maternal protein intake during pregnancy is limited. Insulin-like growth factors (IGF) play a role in early fetal development and maternal protein intake may influence child body composition via IGF-1. The aim of this study was to investigate the association of maternal protein intake throughout pregnancy on cord blood IGF-1 and child body composition from birth to 5 years of age. Analysis was carried out on 570 mother–child dyads from the Randomised cOntrol trial of LOw glycaemic index diet study. Protein intake was recorded using 3-d food diaries in each trimester of pregnancy and protein intake per kg of maternal weight (g/d per kg) was calculated. Cord blood IGF-1 was measured at birth. Infant anthropometry was measured at birth, 6 months, 2 and 5 years of age. Mixed modelling, linear regression, and mediation analysis were carried out. Birth weight centiles were positively associated with early-pregnancy protein intake (g/d per kg), while weight centiles from 6 months to 5 years were negatively associated (B=−21·6, P<0·05). These associations were not mediated by IGF-1. Our findings suggest that high protein intake in early-pregnancy may exert an in utero effect on offspring body composition with a higher weight initially at birth but slower growth rates into childhood. Further research is needed to elucidate the exact mechanisms by which dietary protein modulates fetal growth.
In England and Wales, the question of access to information about deceased persons is determined under two separate statutes: the Access to Health Records Act 1990 and the Freedom of Information Act 2000. This paper examines the normative and legal issues raised by access to information about the dead and evaluates the statutory framework. It draws on philosophical and legal sources which support the claim that the dead are owed a moral and legal duty of confidence. However, it also shows that this is not an absolute duty and it identifies the public and private justifications which favour the provision of access to information about the dead. It argues that the current statutory framework is excessively restrictive and that it fails to provide an appropriate context within which interests favouring access may be considered. Accordingly, it argues that the law needs to be reformed and that a specific legislative framework dealing with access to information about the dead should be introduced. The paper concludes by setting out some preliminary suggestions regarding the possible form of such a legislative framework.
As originally used, the term ‘autonomy’, so central to bioethical debate, had nothing to do with health care or indeed with individuals. Rather, the term described the right of Greek city-states to self-government. With the Enlightenment, the principle of autonomy came to be associated with individuals as well as states and respect for autonomy now provides the philosophical underpinning for much of bioethics and law. While this book is concerned with autonomy in the relatively limited sphere of decisions about treatment, the status to be accorded to individual autonomy is central to many bioethical debates, ranging from access to euthanasia and reproductive technology to the sale of organs or body parts.
Although the importance of autonomy to healthcare ethics and law is clear, what the principle actually means is less so. As Gerald Dworkin notes, ‘[a]bout the only features held constant from one author to another are that autonomy is a feature of persons and that it is a desirable quality to have’. In fact, as this chapter shows, the concept of autonomy is more dynamic and complex than is sometimes appreciated in legal discussions of its role in healthcare decision-making. This chapter establishes the theoretical foundations for the legal discussion which follows in later chapters by exploring autonomy as a philosophical construct within ethical debate. This is important not least because, as Alasdair Maclean notes, the law tends to follow the dominant ethical arguments although with an extensive time lag.
The previous chapter showed that, while the law may reject ‘hard’ paternalism, ‘soft’ paternalism (intervention on the basis of incapacity) remains a fundamental component of the law's approach to healthcare decision-making. As several commentators have pointed out, the operation of the capacity requirement may conceal ‘hard’ paternalism or favour societal interests over those of the individual in a way which may, in fact, be more damaging to a person's autonomy in practice that an overt recognition of limits on the right. Accordingly, an understanding of capacity is essential in order to appreciate what the principle of autonomy means at a conceptual level and how it operates in individual cases.
In adopting any principles in respect of capacity, the law makes normative choices. In the words of the United States President's Commission:
[A] conclusion about a patient's decisionmaking capacity necessarily reflects a balancing of two important, sometimes competing objectives: to enhance the patient's well-being and to respect the person as a self-determining individual.
This chapter examines the normative choices which have been made by the law in respect of capacity. It outlines the features of the current legal standard for capacity in England and Wales as set out in the Mental Capacity Act 2005 (MCA) and evaluates these in terms of consistency with the liberal principle of autonomy, which is recognised as providing the basis for the law in respect of healthcare decision-making.
For many years, the law relating to treatment for a mental disorder has constituted an anomaly within legal systems which purport to privilege and protect the individual's right of autonomy. In many jurisdictions, including England and Wales, Australia, Ireland and New Zealand, mental health legislation limits the right of patients to make decisions in respect of treatment for their mental disorder, regardless of their capacity. Unsurprisingly, this differential treatment of people with mental disorders has attracted criticism from a range of perspectives. Indeed, as discussed in Chapter 1, critiques emanating from the ‘anti-psychiatry movement’ were part of the impetus for the move to an autonomy-based approach to healthcare decision-making more generally. As with the position in respect of people lacking capacity which was discussed in Chapter 5, there has been a significant shift towards more rights-based legal discourse in respect of people with a mental disorder. People with mental disorders come within the ambit of the European Convention on Human Rights (ECHR) and the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Additionally, non-binding instruments setting out specific protections for the rights of patients with mental disorders have been adopted at United Nations and European levels. However, as will be seen below, it is unlikely that any of these human rights instruments will require a substantive reversal of the differential approach taken to the right of autonomy.
This chapter explores the legal and normative framework within which decisions about treatment for a mental disorder are made.
This analysis of the law's approach to healthcare decision-making critiques its liberal foundations in respect of three categories of people: adults with capacity, adults without capacity and adults who are subject to mental health legislation. Focusing primarily on the law in England and Wales, the analysis also draws on the law in the United States, legal positions in Australia, Canada, Ireland, New Zealand and Scotland and on the human rights protections provided by the ECHR and the Convention on the Rights of Persons with Disabilities. Having identified the limitations of a legal view of autonomy as primarily a principle of non-interference, Mary Donnelly questions the effectiveness of capacity as a gatekeeper for the right of autonomy and advocates both an increased role for human rights in developing the conceptual basis for the law and the grounding of future legal developments in a close empirical interrogation of the law in practice.
Although the law may be far from our minds as we try to make healthcare decisions in circumstances which can be difficult and traumatic, in fact, the law plays a central role in the decision-making process. It provides the framework within which we deliberate; it tells us when we can make decisions for ourselves and when we cannot and it dictates what happens to us when our right to make our own decisions is removed. This book critically evaluates the law's engagement with the process of healthcare decision-making and explores ways in which this might be enhanced.
Since the latter part of the twentieth century, the law's approach to healthcare decision-making has centred on ensuring respect for the principle of individual autonomy. In this, the law reflects the predominant ethical status which has been accorded to the principle. Thus, John Stuart Mill's famous aphorism that ‘[o]ver himself, over his own body and mind, the individual is sovereign’ might be seen as the defining summation of principle. This principle is given legal effect in Cardozo J's often-cited dictum that ‘every human being of adult years and sound mind has a right to determine what shall be done with his own body’ Yet, the reality has always been more complex than citations of Mill or Cardozo might suggest. The status of autonomy within ethical discourse has been challenged for almost as long as the principle has been revered, while in a legal context the degree of respect accorded to the principle of autonomy has varied depending on the circumstances in which the principle is called into action.
In Re B (Adult: Refusal of Medical Treatment), Dame Butler-Sloss P described the test for capacity as ‘clear and easily to be understood by lawyers’. In fact, as this chapter shows, while the outline of the legal test may be stated with ease, what the test actually means is far from clear. Lord Phillips CJ was perhaps nearer the mark when he described capacity as ‘an important, but by no means straightforward concept under English law’. The lack of clarity increases the likelihood of assessors including their own views regarding the appropriateness of the patient's decision as part of the assessment of whether or not she has capacity. The legal test, however, represents just one part of the overall framework for capacity assessment in practice. The kind of process employed in testing for capacity is crucial both in ensuring accurate assessments and in developing the capacity of the person assessed, as is required under the Mental Capacity Act 2005 (MCA). In this respect, formal judicial determinations of capacity comprise a very small proportion of such determinations. For the most part, the law has delegated the function of assessing capacity to non-judicial assessors. These are primarily healthcare professionals, and in most serious cases involving healthcare decisions, they are likely to be medical professionals. Furthermore, even when capacity is judicially determined, judicial conclusions are heavily reliant on expert evidence from professionals.
This book has explored the difficult legal and normative questions to which healthcare decision-making gives rise. It has shown that, while the legal status of the autonomy principle appears to be well established and stable, in reality the position is doctrinally less clear and normatively more problematic than classic legal dicta might suggest. This concluding chapter revisits the arguments made in earlier chapters and identifies some of the implications of these arguments for the future development of the law in respect of healthcare decision-making. In doing this, it identifies some of the major themes which have emerged from the discussion throughout the book. Five such themes are explored. These are first, the view of autonomy as achievement or empowerment; secondly, the limitations of capacity as a gatekeeper for the right of autonomy; thirdly, the appropriate role for law in healthcare decision-making; fourthly, the possibilities and limitations of a human rights focus in healthcare decision-making; and, finally, the need for closer empirical interrogation of the law in practice.
Autonomy as empowerment
A recurrent theme throughout this book has been the limitations of the conception of autonomy as non-interference. This account of autonomy, which derives from Mill's liberal view of the individual operating within a sphere of freedom protected from state interference, has been highly influential in the development of healthcare law and ethics. However, this view of autonomy is flawed in a number of respects.
It is perhaps surprising that there is no express reference to a right of ‘autonomy’ (or ‘self-determination’) to be found in any of the leading bills of rights. Rather, the right is part of what Laurence Tribe calls, in respect of the United State Constitution, the ‘invisible constitution’ While this does not diminish the degree of support the right enjoys (not least because the right also has a basis in the common law), it has meant that the ambit of the right receives relatively little legal analysis. Rather, the right tends to be invoked, often in a medical context, without any attempt to fit the right as applied within a broader analytical framework. Since Cardozo J's dictum in Schloendorff v. Society of New York Hospital, the status of autonomy as a principle of non-interference has been largely uncontested in healthcare law. This is not least because, in many ways, respect for this form of autonomy sits comfortably with the law. Not only are the legal tools for enforcing this form of autonomy long established in the tort of trespass, respect for the principle also allows courts to avoid engaging in judgments about the utility or morality of particular conduct and provides neat answers to difficult dilemmas.
This chapter considers the nature of the law's treatment of the principle of autonomy in the context of healthcare decision-making. It begins by outlining the sources of legal support for the principle.
A consequence of the legal and ethical fixation on autonomy has been a lack of conceptual engagement with the position of people who cannot make autonomous decisions. Thus, while one can neatly trace the philosophical lineage of the right of the capable patient to refuse treatment, it is much more difficult to identify a solid philosophical basis for healthcare decision-making for people who do not have capacity. In the absence of an independent theoretical model, the law traditionally dealt with decision-making for people lacking capacity using one of two unsatisfactory approaches. On the one hand, courts in England and Wales viewed a finding of incapacity as justifying a return to full-scale paternalism, where treatment decisions could be made on the basis of the patient's best interests with few safeguards and little analysis. The second approach, preferred by courts in the United States, has been to attempt to extend the principle of autonomy, notwithstanding the patient's lack of capacity, through the application of a substituted judgment standard based on what the patient would have wished had she had capacity notwithstanding, in some cases, very limited evidence of the patient's likely views or preferences. In England and Wales, this unsatisfactory position has begun to change. The Mental Capacity Act 2005 (MCA) contains provisions that allow people to make advance healthcare decisions and which require efforts to be made to facilitate participation by the person lacking capacity in the decision-making process.