School-based Obesity Prevention Research Articles

Barriers and facilitators to the nationwide dissemination of the Dutch school-based obesity prevention programme DOiT.

This article describes the barriers and facilitating factors to the adoption, implementation and continuation of the Dutch Obesity Intervention in Teenagers (DOiT) programme in the Netherlands. We evaluated the adoption, implementation and continuation of the programme at 20 voluntary prevocational schools, which adopted the programme. Interviews were conducted with DOiT coordinators and/or teachers (n = 44) at the end of the first and second school year of the 2-year implementation period. Interviews were recorded and transcribed verbatim. Data were coded by two researchers independently. Identified barriers and facilitating factors were categorized into four groups: (i) organizational factors, (ii) individual factors, (iii) characteristics of the programme and (iv) characteristics of the implementation strategy. Teachers and DOiT coordinators identified various implementation barriers (e.g. lack of planning, other urgent unforeseen priorities, no plan to cope with teacher turnover and high teacher workload) as well as facilitating factors (e.g. involvement of DOiT coordinator and support from the DOiT office, sufficient communication and collaboration between teachers, strong teacher motivation and flexibility of the programme). Overall, DOiT implementers were satisfied with the compatibility, layout, content and potential for tailoring the programme. Barriers for successful implementation were mainly at the school and teacher level. Findings of this study can be used for further improvement of the DOiT programme and for the development and improvement of other health promotion programmes in the school setting.

Preventing obesity among Brazilian adolescent girls: Six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial

BackgroundSchool-based trials to prevent and reduce prevalence of pediatric obesity in low-income countries are necessary. In Brazil, addressing adolescent obesity is a public health priority. ObjectiveTo evaluate the impact of a group randomized controlled trial involving a 6-month multicomponent school-based obesity prevention program targeting adolescent girls. MethodsThe Healthy Habits, Healthy Girls–Brazil program recruited participants (n=253; 16.05±0.05 years) from ten eligible public technical schools in São Paulo, Brazil. The program was adapted from an Australian intervention study, which is based on the Social Cognitive Theory. The primary outcome measure was body mass index (BMI), and secondary outcomes included BMI z score, waist circumference, and various sedentary and dietary health-related behaviours. ResultsAlthough changes in BMI were not statistically significant, differences favored the intervention group (adjusted mean difference, −0.26kg/m2,se SE=0.018, p=0.076). Statistically significant intervention effects were found for waist circumference (−2.28cm; p=, p=0.01), computer screen time on the weekends (0.63h/day, p; p=0.02), total sedentary activities on the weekends (−0.92h/day, p<0.01), and vegetable intake (1.16servings/day, p=0.01). ConclusionThese findings provide some evidence for the benefit of a school-based intervention to prevent unhealthy weight gain in adolescent girls living in low-income communities.

Obesity prevention in English primary schools: headteacher perspectives.

Schools are seen as important contributors to obesity prevention, yet face barriers in fulfilling this function. This qualitative study investigates headteacher views on the primary school role in preventing obesity. Semi-structured interviews were held with 22 headteachers from ethnically and socio-economically diverse schools in the West Midlands, UK. Data analysis was conducted using the framework approach. Two over-arching categories were identified: 'School roles and responsibilities' and 'Influencing factors'. Participants agreed that although schools contribute towards obesity prevention in many ways, a moral responsibility to support children's holistic development was the principal motivator, rather than preventing obesity per se. The perceived impact on learning was a key driver for promoting health. Parents were believed to have the main responsibility for preventing obesity, but barriers were identified. Whilst headteachers recognized the advantageous position of schools in offering support to parents, opinion varied on the degree to which schools could and should take on this role. Headteachers serving more deprived areas reported adopting certain responsibilities that elsewhere were fulfilled by parents, and were more likely to view working with families on healthy lifestyles as an important school function. Several factors were perceived as barriers to schools doing more to prevent obesity, including academic pressure, access to expert support and space. In conclusion, school leaders need more support, through resources and government policy, to enable them to maximize their role in obesity prevention. Additionally, school-based obesity prevention should be an integral part of the education agenda rather than bolt-on initiatives.

Dietary intake and meal frequency of Brazilian girls attending a school-based randomized controlled trial

Purpose – This paper aims to evaluate the effects of a school-based obesity prevention program targeting Brazilian adolescent girls on dietary intake and meal frequency. Design/methodology/approach – It was a six-month school-based group randomized controlled trial with female adolescents. The intervention was based on the Social Cognitive Theory and focused on ten nutrition and physical activity key messages. Diet intake was measured using a validated food frequency questionnaire, and the food items were aggregate into the eight food groups of the Brazilian Food Guide Pyramid. The meals frequency assessed were breakfast, lunch, dinner and snack-in-between-meals, the frequency ranged from never to everyday. Linear mixed models were used to examine the dietary effects and chi-squared test to identify proportional differences among groups in meal frequency. All analyses followed intention-to-treat principles and alpha levels of p ≤ 0.05 were set. Findings – After six months from baseline, changes in the fruits (mean [SE] 12.48 kcal [7.86], p = 0.005), vegetables (8.80 kcal [7.11], p = 0.006) and sugar (−55.98 kcal [50.70], p = 0.036) groups were demonstrated. Proportional difference was shown for snack-in-between-meals (p = 0.001), and the frequency most cited was for “five to six days” per week. Originality/value – The “Healthy Habits, Healthy Girls-Brazil” showed promise in the adolescents’ dietary intake and could be used as framework for future interventions. Also, the methods used for dietary intake can be enhanced and implemented for future studies.

Predictors for Persistent Overweight, Deteriorated Weight Status, and Improved Weight Status During 18 Months in a School-Based Longitudinal Cohort.

To examine predictors for persistent overweight/obesity, deteriorated weight status, and improved weight status among students who participated in a school-based obesity prevention intervention from fall 2009 to spring 2011. Longitudinal assessment of a school-based cohort was conducted to determine the characteristics of students who remained overweight/obese, improved their weight status, or showed deteriorated weight status during an 18-month period. Eleven schools in southern Indiana, northwestern Kentucky, and southeastern Illinois. N = 5309 students in 4th through 12th grade. Weight, height, and self-reported physical activity and nutrition behaviors of students were measured at baseline and 6, 12, and 18 months. SAS 9.3 was employed to examine predictors for the three different weight categories using logistic regression. Low socioeconomic status (SES) (adjusted odds ratio [AOR] = 1.56 and p < .001, AOR = 1.35 and p = .0069, respectively) and higher soda intake (AOR = 1.07 and p = .0016, AOR = 1.08 and p = .0278, respectively) increased the odds of belonging to persistent overweight/obesity (30.6%) and deteriorated weight status (6.9%), compared to the persistent nonoverweight status group. While SES is an important determinant of weight category change, students' screen time and soda consumption may be important factors. Schools and families may be able to successfully focus on these modifiable risk factors, decreasing the burden of childhood obesity.

Mediating effects of resistance training skill competency on health-related fitness and physical activity: the ATLAS cluster randomised controlled trial

The purpose of this study was to examine the mediating effect of resistance training skill competency on percentage of body fat, muscular fitness and physical activity among a sample of adolescent boys participating in a school-based obesity prevention intervention. Participants were 361 adolescent boys taking part in the Active Teen Leaders Avoiding Screen-time (ATLAS) cluster randomised controlled trial: a school-based program targeting the health behaviours of economically disadvantaged adolescent males considered “at-risk” of obesity. Body fat percentage (bioelectrical impedance), muscular fitness (hand grip dynamometry and push-ups), physical activity (accelerometry) and resistance training skill competency were assessed at baseline and post-intervention (i.e., 8 months). Three separate multi-level mediation models were analysed to investigate the potential mediating effects of resistance training skill competency on each of the study outcomes using a product-of-coefficients test. Analyses followed the intention-to-treat principle. The intervention had a significant impact on the resistance training skill competency of the boys, and improvements in skill competency significantly mediated the effect of the intervention on percentage of body fat and the combined muscular fitness score. No significant mediated effects were found for physical activity. Improving resistance training skill competency may be an effective strategy for achieving improvements in body composition and muscular fitness in adolescent boys.

The Impact of Family Rules on Children's Eating Habits, Sedentary Behaviors, and Weight Status.

Family rules may be influential in helping children to modify their dietary and sedentary behaviors, which are important modifiable risk factors for childhood obesity. However, data examining family rules in relation to children's health behaviors and weight status are limited. This cross-sectional study examined differences in family rules by demographic characteristics of students enrolled in the HEROES (Healthy, Energetic, Ready, Outstanding, Enthusiastic Schools) Initiative, a school-based childhood obesity prevention program. It also investigated the relationship between eating and screen time family rules and six eating and screen time behaviors: fast food consumption; soft drink consumption; fruit and vegetable intake; television viewing; computer use; and video game use, in addition to the association between family rules and children's weight status. Measures included self-reported behavioral data and anthropometric data from students in fourth to eighth grade at 16 schools (N=2819) in a tri-state area of the United States in spring 2012. Approximately one-third of students had each of the family rules examined. Whereas the profile of students who had specific rules varied, in general, younger, female, white, and low socioeconomic status students were more likely to have rules than their counterparts. Family rules were associated with healthier outcomes for each of the six behaviors examined (p<0.001), even after controlling for demographics (p<0.001). However, family rules were not associated with children's weight status. This study demonstrates that family rules are an underutilized strategy to promote healthier eating habits and reduce children's screen time hours and may serve as an intermediary mechanism to curb childhood obesity.

Perceptions and attitudes towards food choice in adolescents in Gaborone, Botswana

The purpose of this qualitative study was to describe the factors that influence adolescent and adult perceptions and attitudes related to adolescent diet in Botswana. A series of 15 focus groups [12 adolescent focus groups (6 male and 6 female) & 3 parent focus groups] of approximately six to eleven members each were conducted in Gaborone, the capital city of Botswana in 2009–2010. Adolescents and parents of adolescents suggest that the main drivers of adolescent food choices have much to do with where the adolescent is in terms of time of day as well as with whom the adolescent is with. Outside of the home adolescents suggest that the real or perceived influence of companions place social standing on the ability to purchase and consume non-traditional foods, and that traditional foods leave adolescents open to ridicule. Additionally parents of adolescents suggest that while they prefer for their children to consume healthy foods, they frequently purchase unhealthy food items for their children based on the child's taste preferences as well as social influence to prove you can buy “nice things” for one's family. Adolescents and parents of adolescents suggest that increasing the availability and decreasing the costs of healthy food options are preferred possible interventions to increase healthful eating among adolescents. However, the adolescents also suggest that these healthy food options should not crowd out or completely replace unhealthy options, thus preserving the adolescents' freedom to choose. This could pose a major challenge in any school-based adolescent obesity prevention program.

Wellness Councils Build Capacity for School-Based Obesity Prevention in Harlem and Washington Heights, New York City

Schools experience barriers when implementing wellness policies, and there is a dearth of research detailing how district wellness policies are implemented at the school level. Wellness councils were established in 7 elementary schools in Harlem and Washington Heights, New York City (NYC), to help these schools implement the NYC district wellness policy. Data on 4 wellness council process indicators and wellness council self-evaluation scores were correlated with obesity prevention process outcomes using Kendall tau correlations. An average of 8.9 (standard deviation = 0.7) wellness council meetings were held per school throughout the 10-month academic year. The average attendance at each meeting ranged from 7.1 to 15.2 members. There was a positive relationship between wellness council attendance and the number of participant encounters at staff physical activity events ( r = .71, P = .02). Higher self-evaluation scores on staff wellness initiatives were associated with more student nutrition encounters ( r = .69, P = .04) and in-class student physical activity minutes ( r = .69, P = .04). The wellness councils served as a forum for regular interaction between health professionals and school staff and allowed for evidence-based interventions to be adapted to local school needs and culture. School staff engagement is important for successful obesity prevention initiatives and should be a goal of school-based wellness programs.

A systematic review of the effectiveness of school-based obesity prevention programmes for First Nations, Inuit and Métis youth in Canada.

First Nations, Inuit and Métis (FNIM) youth are disproportionately affected by obesity and represent known a high-risk group in Canada. School-based prevention programmes may have the potential to effectively influence obesity-related health behaviours (i.e. healthy eating and physical activity) among this population. We conducted a systematic review of nine electronic databases (2003-2014) to identify studies that describe school-based programmes that have been developed to improve obesity-related health behaviours and outcomes among FNIM youth in Canada. The objectives of this review were to identify and evaluate the effectiveness of these programmes and assess the strength of the methodologies used to evaluate them. Fifteen studies, representing seven distinct interventions, met our inclusion criteria. The majority of these programmes did not result in significant improvements in outcomes related to obesity, healthy eating, or physical activity among FNIM youth. The studies varied in design rigour and use of evaluation activities. The lack of literature on effective school-based programmes for FNIM youth in Canada that target obesity-related outcomes highlights a priority area for future intervention development, evaluation and dissemination within the peer-reviewed literature. Further research is needed on interventions involving Métis and Inuit youth, secondary school-aged FNIM youth and FNIM youth living in urban settings.

Nurse-Led School-Based Child Obesity Prevention.

School-based childhood obesity prevention programs have grown in response to reductions in child physical activity (PA), increased sedentariness, poor diet, and soaring child obesity rates. Multiple systematic reviews indicate school-based obesity prevention/treatment interventions are effective, yet few studies have examined the school nurse role in obesity interventions. Building on a previous study, this study examines a refined health messaging (Let's Go 5-2-1-0) program delivered to fourth and fifth graders (n = 72) by a school nurse with reinforcement on-site health coaching by senior nursing students. Two nursing schools and two elementary schools participated. Measures of PA, body mass index percentile, and self-reported health habits were collected at baseline (School A, September 2009 and School B, January 2010) and end of year (April 2010 for both schools). Findings included statistically significant increases in PA levels and improvements in child-reported health habits. School nurses can influence obesity prevention. Further research on adoption of school nurse-led obesity interventions is warranted.

A national school-based health lifestyles interventions among Chinese children and adolescents against obesity: rationale, design and methodology of a randomized controlled trial in China.

BackgroundThe prevalence of obesity among children and adolescents has been rapidly rising in Mainland China in recent decades, both in urban and rural areas. There is an urgent need to develop effective interventions to prevent childhood obesity. Limited rigid data regarding children and adolescent overweight prevention in China are available. A national random controlled school-based obesity intervention program was developed in the mainland of China.Methods/DesignThe study was designed as a national multi-centered cluster randomized controlled trial involving more than 70,000 children and adolescents aged 7–18 years from 7 provinces in China. In each center, about 12–16 primary and secondary schools, with totally at least 10000 participants were randomly selected (Primary: Secondary = 1:1). All of the selected schools were randomly allocated to either intervention or control group (Intervention: Control = 1:1).The multi-components school-based and family-involved scheme was conducted within the intervention group for 9 month, while students in the control group followed their usual health practice. The intervention consisted of four components: a) Create supportive school and family environment, b) Health lifestyles education and related compulsory physical activities, c) Instruct and promote school physical education, d) Self-monitor obesity related behaviors. Four types of outcomes including anthropometric, behavioral, blood chemical and physical fitness were measured to assess the effectiveness of the intervention program.DiscussionThis is the first and largest multi-centered school-based obesity intervention program with the consideration of geographical and social-demographic characteristics of the rapidly increased obesity prevalence of Chinese children and adolescent. The intervention is based on Social Cognitive Theory and Social-Ecological Model of Health, and follows a stepwise approach guided by PRECEDE-PROCEED (P-P) Model and Intervention Map. The results of and lesson learned from this study will help guide future school-based national childhood obesity prevention programs in Mainland China.Trial registrationJanuary 22, 2015; Registration number: NCT02343588

The role of parents in public views of strategies to address childhood obesity in the United States.

POLICY POINTS: The American public--both men and women and those with and without children in the household--holds parents highly responsible and largely to blame for childhood obesity. High attributions of responsibility to parents for reducing childhood obesity did not universally undermine support for broader policy action. School-based obesity prevention policies were strongly supported, even among those viewing parents as mostly to blame for childhood obesity. Americans who viewed sectors outside the family (such as the food and beverage industry, schools, and the government) as helping address childhood obesity were more willing to support a wider range of population-based obesity prevention policies. The public's views of parents' behaviors and choices--and the attitudes held by parents themselves--are likely to influence the success of efforts to reverse obesity rates. We analyzed data from 2 US national public opinion surveys fielded in 2011 and 2012 to examine attributions of blame and responsibility to parents for obesity, both among the general public and parents themselves, and we also explored the relationship between views of parents and support for obesity prevention policies. We found that attribution of blame and responsibility to parents was consistently high, regardless of parental status or gender. Support for policies to curb childhood obesity also did not differ notably by parental status or gender. Multivariable analyses revealed consistent patterns in the association between public attitudes toward parents' responsibility and support for policies to curb childhood obesity. High parental responsibility was linked to higher support for school-targeted policies but generally was not associated with policies outside the school setting. Attribution of greater responsibility to entities external to children and their parents (schools, the food and beverage industry, and the government) was associated with greater support for both school-targeted and population-based obesity prevention policies. Our findings suggest that the high attribution of responsibility to parents for reducing childhood obesity does not universally undermine support for broader policy action. But appealing to parents to rally support for preventing obesity in the same way as for other parent-initiated social movements (eg, drunk driving) may be challenging outside the school setting.

We can do that! Collaborative assessment of school environments to promote healthy adolescent nutrition and physical activity behaviors.

Evidence for effectiveness of school-based studies for prevention of adolescent obesity is equivocal. Tailoring interventions to specific settings is considered necessary for effectiveness and sustainability. The PRECEDE framework provides a formative research approach for comprehensive understanding of school environments and identification of key issues/areas to focus resources and energies. No reported studies have tested applicability of the PRECEDE framework in schools in relation to obesity. Adolescents (n = 362), parents (n = 349) and teachers (n = 146) from six secondary schools participated in two quantitative studies and two qualitative studies. Data collected from these studies permitted confirmation of adolescent overweight/obesity a health issue for schools; the need for secondary schools to focus health promotion efforts on healthy nutrition, with inclusion of parents/homes and appreciation for gender differences in developing interventions. Community buy-in and commitment to school-based obesity prevention programs may be dependent on initially addressing what may be perceived as minor issues, and developing policies to guide practices within schools in relation to supply and access to healthy foods, use of sporting equipment and participation in physical activities. The PRECEDE framework allows systematic assessment of school environments and provided opportunity to identify realistic and relevant interventions for promoting healthy adolescent physical activity and nutrition behaviors.

Parent and child perspectives on a school-based obesity prevention intervention. The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study

Parent and child perspectives on a school-based obesity prevention intervention. The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study

School-based adolescent obesity prevention programming: perceptions of school personnel in Southern Appalachia.

Coordinated School Health (CSH) is a systematic approach to improving the health and well-being of school-age children. It is recommended for its potential to promote healthy weight in adolescents through strategic programming. Resources and programming for adolescent obesity prevention varies among schools, thereby limiting the intended benefits of CSH. The purpose of this study was to understand gaps in schools' approaches to healthy weight promotion and support for overweight/obese students. We evaluated perceptions of adolescent obesity and environmental factors and programs facilitating healthy weight in high schools in Appalachian Tennessee. In 2012, 17 key school personnel from 5 randomly selected high schools were interviewed. Questions addressed their perceptions of adolescent obesity, school-based physical activity and nutrition programming, and support available to overweight/obese students. Thematic analysis was conducted to identify emerging themes. Participants consistently identified adolescent obesity and/or associated risk factors as major health problems within their schools. Barriers to physical activity and healthful eating were identified at multiple levels. Because of the sensitivity surrounding overweight/obesity, no particular programs or curricula targeted overweight/obese adolescents specifically, but they were available to all students. Support is not explicitly available; therefore, overweight/obese students must seek out these resources. Findings suggest that although school personnel are concerned about the impact of adolescent obesity on health outcomes, there is wide variation across schools on the types and quality of programming available to address the issue. Results can be used to encourage school-based strengths and identify gaps in the CSH infrastructure in school systems.

A meta-analysis of school-based obesity prevention programs demonstrates limited efficacy of decreasing childhood obesity

Childhood obesity is a global concern. The objectives of this meta-analytical study were to evaluate the effectiveness of school-based childhood obesity prevention programs, and to examine program components (moderators). The methods included searching databases (PubMed, Google Scholar, and the university's EBSCOhost Web service) as well as handsearching reference lists of articles published in English. Selection criteria for studies to be included in the meta-analysis were limited to studies that reported body mass index (BMI) or skinfold thickness as outcome measures and were school-based obesity prevention interventions; cross-sectional design studies were excluded. We hypothesized the meta-analysis would yield a summary effect size of magnitude which would indicate that school-based interventions have been effective in improving children's BMI or skinfold thickness values. A total of 26 114 children from 27 school-based childhood obesity prevention programs provided 54 effect sizes. A random-effects model calculated a small summary effect size of 0.039 (95% confidence interval −0.013 to 0.092). Heterogeneity among studies was observed which disappeared after pooling studies that used a randomized controlled trial design with one program moderator (physical activity or nutrition). We failed to accept our hypothesis and concluded that overall, school-based interventions have not been effective for improving body mass index or skinfold thickness to curb childhood obesity; however, randomized controlled trials that focused on physical activity or nutrition appeared to produce promising results.

Comment on “School-Based Obesity Prevention Intervention in Chilean Children: Effective in Controlling, but not Reducing Obesity”

We read with interest the article “School-Based Obesity Prevention Intervention in Chilean Children: Effective in Controlling, but not Reducing Obesity” [1], hereafter “the article.” In the article [1], nine schools were randomized into intervention and control groups according to the socioeconomic conditions of the children (a stratified randomization design at the cluster level), resulting in five schools in the intervention condition and four schools in the control. The intervention consisted of training teachers to deliver content on healthy eating and to improve the quality of physical education classes. The primary outcome was change in BMI Z score between baseline and follow-up. This is a typical cluster randomized controlled trial (cRCT) in which the inferences are intended to apply at the individual (student) level while randomization is at the cluster (school) level [2, 3]. In cRCTs, the potential lack of independence among individuals in the same cluster, that is, intracluster correlation (ICC), creates special methodological issues in both design and analysis. Any individual level analysis without considering the clustering is invalid [3]. Unfortunately, the article [1] ignored the clustering in its sample size estimation and final data analysis, which potentially increased type I and type II error rates and put their conclusions in doubt. The article [1] claims the study as a cluster randomized trial; however, the power and sample size estimation in Section 2.1 completely ignores the facts that (1) the sample size of cRCTs consists of cluster number (K) and cluster size (m), (2) the power is more dependent on the cluster number than cluster size [2], and (3) the “design effect” is caused by the similarity of individuals in the same cluster [2, 3]. The presentation of study sample sizes described in Section 2.1 is therefore misleading and might confuse readers. More severely, ignoring the clustering in the final data analyses of cRCTs (as done in the article [1]) will cause inflated type I error rates by (1) underestimating the variance of intervention effects and (2) using the extremely magnified degrees of freedom (df) in the hypothesis testing. The fact that clusters are nested within intervention conditions makes the df available to estimate the intervention effects much smaller than the df without nested clusters. For a hypothetical cRCT with m persons nested within K clusters across c experimental conditions, there will be N = c∗K∗m total persons. Because of the impact of clustering, the df for estimating the between cluster variance is the number of conditions multiplied by the number of clusters minus one, or df = c∗(K − 1), which is far smaller than c∗(K∗m − 1), used in the article [1]. Considering only nine schools that are involved in the trial, the Kenward-Roger small sample df approximation [4] should also be recommended, which has been implemented in some commercial statistical packages including SAS and R. Furthermore, in order to improve the transparency and utility of cRCTs, the CONSORT 2010: extension to cluster randomized trials [5], states that the ICC and an indication of its uncertainty are to be reported in describing (1) how the sample size is determined and (2) how clustering is taken into account in the statistical analysis. In addition, the reported ICCs are also helpful for those who may subsequently perform similar (replication) studies. To evaluate the validity of this study, we conducted a permutation/randomization test for the difference in change of BMI Z scores, using the data in Table 2. Although the major conclusion of the study—in which the school-based treatment prevented increase in BMI Z scores compared to control schools—does have statistical merit (permutation P < 0.03), we suggest that the authors redo their analyses taking the clustering into account and report the unconditional ICC (or constituent variance components) and its confidence interval for better practice.

Implementation evaluation of school-based obesity prevention programmes in youth; how, what and why?

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A comprehensive review of school-based body mass index screening programs and their implications for school health: do the controversies accurately reflect the research?

Whereas legislation for body mass index (BMI) surveillance and screening programs has passed in 25 states, the programs are often subject to ethical debates about confidentiality and privacy, school-to-parent communication, and safety and self-esteem issues for students. Despite this debate, no comprehensive analysis has been completed that compares and contrasts how these issues differentially affect schools, parents, and students. A keyword search from electronic databases and a review of state legislation related to BMI surveillance and screening were used to identify relevant literature and data focused on surveillance and screening policies, BMI report cards, and parental perceptions of BMI screenings and their child's weight status [corrected]. This article addresses the gap of previous literature by outlining the ethical considerations and implications that BMI screening programs and report cards have for schools, parents, and students, and links these with outcome studies to address whether these controversies are supported by research. Despite the controversies surrounding these programs, this review shows that they can be valuable for all parties and demonstrates BMI screening programs to be vital to the development of robust school-based obesity prevention programs and promotion of healthy lifestyles in schools.