Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 1-6

Ethical issues of monitoring children's weight status in school settings

Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

Date of Web Publication29-Jan-2019

Correspondence Address:
Dr. Chung-Ying Lin
Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom
Hong Kong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SHB.SHB_45_18

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How to cite this article:
Lin CY. Ethical issues of monitoring children's weight status in school settings. Soc Health Behav 2019;2:1-6

How to cite this URL:
Lin CY. Ethical issues of monitoring children's weight status in school settings. Soc Health Behav [serial online] 2019 [cited 2024 Feb 29];2:1-6. Available from:

  Introduction Top

The prevalence of overweight and obesity is rapidly rising in many countries.[1],[2],[3],[4],[5],[6] In the United States, the prevalence of overweight – which has nearly tripled during the past two decades – was 13%–14% of children aged 6–19 years in 1999.[6] As during the 1999–2002 period, 31% and 16% of the children aged 6–19 years were at risk of overweight and overweight, respectively.[7] In the United Kingdom (UK), the prevalence of obesity was from 10% to 14% in children aged 2–10 years between 1995 and 2003; in children aged 8–10 years, the prevalence even rose from 11% to 17%. In France, although the prevalence of overweight did not seem to be increasing, 18.7% in 1995[8] and 15.2% in 1998,[9] the prevalence of overweight was still high. In 1980, the prevalence of overweight in Taiwan was 12.4% in boys and 7.2% in girls but rose to 16.4% in boys and 16.9% in girls by 1994.[2] By 2000, nearly one-third of the boys and one-fourth of the girls in Taiwan were overweight or obese.[3] Thus, many countries face the same public health problem: their children are at serious risk for overweight/obesity.

The definition of overweight and obesity in most studies is based on body mass index (BMI), which is computed by weight (kg) divided by height square (m2).[3],[10],[11],[12],[13],[14],[15] Although some research has considered that the BMI of obesity is higher than the BMI of overweight,[3],[12] one review article used overweight and obesity interchangeably.[16] Because we considered the influences of overweight and obesity on individuals to be almost the same, we also used overweight and obesity interchangeably to represent the same meaning of excess weight in our article.

We are concerned about the increasing prevalence of overweight because of the risks from overweight. Numerous research studies have suggested that compared to normal weight individuals, overweight individuals have a higher risk of incurring cardiovascular diseases and type II diabetes,[17],[18] poorer physical fitness,[19],[20] lower self-esteem,[21] and worse quality of life.[22],[23],[24],[25],[26] To prevent children from becoming overweight, one suggestion for government policy is to monitor children's weight status in school settings, which has been begun in some United States (US), the UK, and Taiwan.

However, weight monitoring in schools may result in negative impact on obese children. Previous studies have suggested that obese children are often experience being laughed at and stigmatized by peers.[16],[27],[28],[29] Thus, the screening of BMI may result in children with higher BMI of being stigmatized as fat or heavy by their classmates. In addition, lower body image, increased body dissatisfaction, and disordered eating are also indicated as potential harmful results to overweight children of monitoring the children's weight.[30] Media nowadays spread the information that thinness is beautiful, whereas obesity is ugly;[31] children who find that they are heavy after BMI screening may be dissatisfied with their body image, leading to disordered eating behaviors. Thus, a thoughtful discussion of weight monitoring in school settings is needed. In addition, a considerably practical method of weight monitoring in school settings should also be considered.

Although Ikeda et al. discussed the potential benefits and harms of BMI screening in school settings and proposed some practical guidelines, no research has used the view from ethics to discuss the policy of weight monitoring.[30] We suggest that using the view of ethics can help us consider the policy of weight monitoring more thoughtfully. Thus, the purposes of this article are to discuss the policy of weight monitoring by ethical points and to suggest an appropriately practical way to monitor the weight status of children.

  Policies of Weight Monitoring in School Settings Top

The United States

In 2001, the surgeon general considered the problems of overweight in America and issued a “Call to Action to Prevent and Decrease Overweight and Obesity” to face this public health problem.[6] In response, the Arkansas state legislature required schools to calculate students' BMI and to send parents a “BMI report card.” Tennessee passed legislation allowing schools to monitor students' weight status but not forcing them to do it. However, proposed legislation requiring school reporting of BMI to parents came up against strong resistance in Texas and Michigan.[30],[32] The major reason of the different attitudes toward the call for action may be because of the uncertainty as whether this practice would be helpful or harmful. Hence, the issue of “BMI screening in school settings” has been outlined and discussed.[33]

The United Kingdom

The UK has developed national guidelines on screening children's weight status in school settings. Two purposes are cited in the national guidelines: (1) informing local planning, targeting of local resources, and giving interventions and (2) enabling tracking of local progress against the goal of the target on obesity (i.e., halting the year-on-year rise in obesity among children under the age of 11 years by the year 2010) and local performance management. This screening is to be carried out among all primary schoolchildren twice: (1) the reception year (age: 4–5 years) and (2) at the 6th grade (age: 10–11 years). Parents are informed by schools that their children will be weighed; however, parents can choose to let their children out of the measuring process.


In Taiwan, schools have measured the weight and height of children at the beginning of each semester for years. However, this kind of weight screening has not prevented the increasing prevalence of overweight. Thus, in 2008, the government decided to implement the policy of “improving health of students.” The policy suggests that schools require analyzing the weight status of each student according to the definition of overweight in children and adolescents. In addition, schools need to consult with those who are not in normal weight status and follow up the performance management. However, the understanding of healthy weight status and the methods of effectively monitoring weight status in students are still immature. Furthermore, although the policy suggests that consultation and management are needed, practical methods need to be developed. The goals of the policy are as follows: (1) to help students grow up healthily, (2) to monitor the physical development and follow up abnormal weight status students as client management (management rate is suggested to be 70% and 90% in 2008 and 2010, respectively), (3) to help students have correct sense of body images, and (4) to decrease the prevalence of overweight and obesity.

  Bioethics and Four Principles Top

Ethics has been defined as “a generic term containing several ways to examine and to understand the moral life.”[34] However, using the whole concept of ethics to discuss in our article seems not appropriate because that discussion might be so theoretical rather than practical. Thus, we narrowed the ethical issues into practical ethics, which can be used to interpret general ethical norms for purposes of addressing different problems and contexts.[34] Furthermore, since the issue in our article is health, we consider that ethics about health care (i.e., bioethics)[35] is more suitable than general ethics.

Since bioethics was developed for the purpose of biological and health sciences and has prospered in recent years,[34] we are confident that using bioethics to discuss the issue of weight monitoring in school settings can help us consider the overweight/obesity issue more thoroughly. In addition, professional health-care staffs are required to have knowledge of bioethics[36] in order to make the best decisions for their clients, and the main purpose of bioethics is to promote each individual's health and to prevent harm or death.[36] Thus, bioethics supplies the considerably practical principles for health-care decision-making, such as the process of weight monitoring in school settings.

Four principles are commonly used in bioethics: autonomy, beneficence, nonmaleficence, and justice.[36] Thus, we introduced the concept of the four principles and then examined and discussed the policy of weight monitoring in school settings according to these principles in this article.

The term autonomy comes from the Greek auto (self) and nomos (rule and governance) and thus refers to the meaning of “self-rule” or “self-governance.”[36],[37] As each individual can self-rule, three basic elements are needed: (1) the ability to decide. Without sufficient information and intellectual competence, autonomy seems useless; (2) the power to act on your decisions. Without the power to make the decisions seems similar to having no ability to decide; and (3) respect the individual autonomy of others. It is the process of ennobling and professionalizing.[36]

In common English usage, the term beneficence suggests acts of mercy, kindness, and charity.[36],[38] Health-care professionals consider beneficence as “applying measures for the benefit of the sick;”[36] however, when considering the policies, the role of beneficence becomes utilitarianism.[38] In other words, the benefits are considered for the society more than for each individual.

Nonmaleficence means doing no harm;[39] however, the concept of nonmaleficence is easily confused with beneficence.[36] Thus, we distinguished the two principles by the following hierarchical ordering:[34]

  • Nonmaleficence

1. One ought not to inflict evil or harm.

  • Beneficence

2. One ought to prevent evil or harm

3. One ought to remove evil or harm

4. One ought to do or promote good.

According to this hierarchical ordering, we can easily know that nonmaleficence focuses on inhibited behaviors, whereas beneficence focuses on helpful behaviors.[39]

The principle of justice is explained by the concepts of fairness, desert, and entitlement.[36],[40] As in health-care settings, health-care providers and health-care users are usually facing the distribution of scarce resources, and distributive justice is often used to deal with such situation.[41] In addition, several rules are used to determine distributive justice: (1) equal share in each person, (2) distribution according to need in each person, (3) distribution according to effort in each person, (4) distribution according to contribution in each person, (5) distribution according to merit in each person, and (6) distribution according to payment ability in each person.[36],[40] However, although the six rules seem valid and acceptable by the theories of justice, the use of different contexts needs to be considered.[40]

  Weight Monitoring Based on Ethical Principles Top


Each individual has the right to self-rule;[37],[41] thus, we need to consider the autonomy of children who participate in the process of weight monitoring. In addition, because children are considered to be without full ability to be autonomic,[41] we also need to be concerned with their parents' opinions. If the process of weight monitoring is executed without informing children and their parents, that would conflict with the ethics of autonomy.[36],[37] In addition, the information of the process needs to be detailed in order to help children and parents make the best decisions.

Although parents can be the proxy decision-maker of their children, a concern is whether the parents have the ability to make the best decisions for their children. Furthermore, a debate will happen when the parents persist in different decisions toward the process of BMI screening. Moreover, if the children make another decision different from either their father or their mother, the situation would be more complicated. Thus, we need to set up a procedure to help children have the best decision regarding the process of weight monitoring when the debate of autonomy is happening among children and parents.


Considering beneficence, we need to consider all the benefits from the process of weight monitoring. Two levels are discussed independently: individual level and social level. In individual level, we analyze the help from weight monitoring toward both the children and their parents. In social level, the benefits from weight monitoring to society are discussed.

By weight monitoring, children and their parents can get the information of children's BMI and the suggested BMI range. According to the weight information they gain, strategies for maintaining or losing the children's body weight can be set up. Thus, children can keep or promote their physical condition and become healthy. In addition, overweight individuals can gain their confidence, enhance mental health, and improve their quality of life as they lose weight successfully.[42],[43],[44] Furthermore, individuals can have normal interactions with peers after losing weight.[43] Hence, parents can worry less about physical health, mental health, and social interaction in their children. In other words, parents can also benefit indirectly on their psychosocial health from the process of weight monitoring in school settings.

In social level, we discuss the cost in medical resources. Studies have found that overweight places people at risk for many physical diseases, such as cardiovascular disease and type II diabetes,[17],[18] and costs social resources.[45],[46],[47],[48] Since the process of weight monitoring is suggested to be helpful to decrease the prevalence of overweight,[30] we consider there is an indirect beneficial effect of reducing cost in medical resources.


In nonmaleficence, we discuss all the possible harms on children, especially overweight children, caused by weight monitoring. Children with greater BMI would be classified as “fat” or “fatty” by their classmates who find out the results of the BMI screening. As we mentioned before, overweight children are often teased or stigmatized by peers.[16],[29],[49] Thus, children with greater BMI who are stigmatized by “overweight” or “obesity” could be laughed at and isolated by peers. Hence, the process of BMI screening would jeopardize the psychosocial health of the children who have greater BMI but do not have obviously fat body shape. In addition, as for the children who have obviously fat body shape, they could encounter more laughter and crucial discrimination than before the BMI screening.

BMI screenings help the children know more about their body shape and health condition. However, if the information of the BMI interpretation that the children derived is biased, children would be subjected to negative impacts on themselves. A majority of media that children have contact with spread information that is biased toward weight status, such as obesity is ugly, overweight results in unsuccess, leanness is beautiful, and leanness has better chance.[31] The children with greater BMI will be unsatisfied with their body image if they cannot interpret or accept their BMI correctly. As studies have suggested, children with unsatisfied body image often have inappropriate behaviors that could cause harm on them.[49] Thus, children with greater BMI after BMI screening face the threats of having inappropriate or harmful behaviors in order to decrease their BMI.

A threat of resulting in low self-esteem to overweight children is likely to happen after BMI screening.[29],[49] Children with greater BMI are at risk of being laughed at by peers and to be unsatisfied with their body image. In addition, they are forced to remember their excess weight even if they would like to cope with their weight status by forgetting. Thus, after the repetition of laughing and reminding of their excess weight, overweight children would often have lower self-esteem, resulting in abnormal development during their childhood.


If the process of weight monitoring is decided to be practiced, a question will arise: “Does every child have the same procedure of weight monitoring?” In other words, we need to examine whether the children have a fair chance of being weight monitored or not. Moreover, the following procedure after the process of weight monitoring needs to be fairly practiced on the children as well: a thorough, continued procedure (including the intervention on children with abnormal weight status) dealing with all the children according to their weight status after weight monitoring is needed.

In the US, different states take different attitudes toward the policy of weight monitoring.[32] Thus, we question whether American children have an equal right in weight monitoring. Whereas, in the UK and Taiwan, it seems that children have a fair right in weight monitoring. However, another question is “do schools in the country and city share the same resources of weight monitoring?” Because the process of weight monitoring contains the instruments for weight monitoring, the instruments should not be differentiated between different cities and countries (i.e., expensive instruments in the city, whereas cheap instruments in the country) under the ethics of justice. Furthermore, the resources of intervention after weight monitoring should be fairly given for all the abnormal weight children, whether they are in a big city or a small town.

  Suggestions and Implication Top

We suggest that the policy of weight monitoring is helpful for decreasing the prevalence of overweight.[30] In addition, other controversial issues may need to be resolved. Thus, according to the discussion of the ethics issues above, we point out four suggestions for the practical implication of weight monitoring.

First, the autonomy of children and their parents needs to be respected. Both children and parents need to be informed the detailed information including all the possible risks and benefits from weight monitoring by health-care professionals. If the parents have the ability to make the best decision, they can decide to let their children join the weight monitoring process or not after the negotiation between parents and children. If the parents cannot make the best decision, involvement from professionals is needed. Professionals need to analyze the condition of the children thoroughly and make the best decisions for the children.

Second, the following procedures are needed for increasing benefits and decreasing harm after weight monitoring. Monitoring weight can let the children and their parents gain the information of children's weight status; however, we conjecture that it is not enough for the purpose of decreasing or increasing BMI. Following an intervention toward abnormal weight children (i.e., overweight or leanness) needs to be set up to help them gain the health benefits. In addition, harm from weight monitoring needs to be prevented. Children may not be comfortable with the outcomes from weight monitoring. Thus, health professionals intervening to help children adapt with weight status outcomes is suggested. Harm may possibly come from peers' inappropriate behaviors, such as isolation and laughing. Hence, teaching all children to have correct attitudes and behaviors toward abnormal weight children is another issue of concern.

Third, the right of each joined the process of weight monitoring needs to be fair. This suggestion is based on the ethics of justice. We cannot give unfair process according to the background of each child. Although the goal of the policy of weight monitoring is to decrease the prevalence of overweight in children, we cannot neglect the right of children with other kinds of weight status. All the children should have equal right to get the best benefits from the policy. Thus, all the instruments for weight monitoring should be as equal as possible. In addition, after the monitoring, all the overweight and lean children have an equal right to receive the intervention for losing weight and gaining weight, respectively. Furthermore, all children – whether overweight, normal weight, or lean – have an equal right to get the information about health and weight from health-care professionals.

Fourth, all the processes cannot be disclosed without permission from children and parents. Because the disclosure could do harm to the children, such as their dignity, a disclosed process is needed during the whole procedure of weight monitoring (including the subsequent intervention).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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