Our findings suggest a number of consistent themes among high school principals and food service personnel regarding the school environment and its impact on obesity. Both principals and food service personnel believed that obesity was a problem in general; however, they did not feel it was a problem at their school, despite nearly one-fourth of students having a BMI ≥ 85th percentile. These findings mirror data from the family literature, which suggest that parents struggle to accurately identify their child as at risk for or overweight [20–22], and indicate a need to increase obesity awareness among school personnel and parents. Despite concerns about privacy, stigmatization, and appropriate follow-up services, the Institute of Medicine endorses BMI reporting by schools  and data support the effectiveness of this practice. Specifically, in a recent study, parents of overweight children who received a health report card of their child's BMI percentile and risk category were more aware of their child's weight status and health risk and were more likely to consider seeking appropriate dietary, physical activity, and medical care compared to parents not receiving this information . Many schools already complete annual height, weight, or body mass screenings . Generating BMI percentiles and notifying parents of the results represents a logical next step towards increased awareness and improved surveillance and early prevention efforts involving both parents and schools.
All personnel felt schools had been unfairly targeted as the cause of adolescent obesity, and they believed that schools should be only part of a larger solution that included parents, government, and communities. It is important to note the many principals expressed discomfort describing obesity as a 'problem,' citing that it was a 'problem' only when it began to interfere with students' physical and mental health and/or their academic achievement. This distinction is important and represents a possible disconnect between the perceptions of public health and government officials and school administrators. The majority of school-based research and/or policy-based initiatives are currently framed in terms of obesity prevention and wellness; administrators may be more likely to engage in these initiatives if they are seen as positively impacting the factors of most importance to their school, including student's physical and mental health and/or their academic achievement.
Although both principals and food service personnel believed schools should be a part of the solution, they offered different perspectives regarding the specific roles schools could play. Principals largely focused on changes to the overall structure of the school day, which included adding more structured wellness and/or nutrition/physical activity instruction. Food service personnel focused heavily on education as a way to address obesity and the importance of choice in the education process. The food/beverage offerings seemed largely governed by their mission of educating through choice. While some acknowledged that improvements to the food environment could be made, the majority expressed satisfaction with their food service program and saw little need or room for change. Almost universally, food service personnel mentioned that at least half of their ALC food items were 'healthy,' although definitions of what constituted a 'healthy' item differed. Most also mentioned that students choosing to eat healthy could certainly do so. Interestingly, many personnel believed that limiting choice would interfere with the education process, and although not explicitly stated, was perceived by some to be a disservice to students.
The perceived role of educating through choice is in contrast to many of the current policy-based initiatives, which seek to limit choices, and to much of the literature on the impact of availability on students' choices and dietary intake. Within the school environment, the availability of energy dense, nutrient poor foods through ALC and vending has been found to adversely impact the nutritional quality of students' diets by displacing the consumption of healthy foods (e.g., fruits, vegetables, milk) and contributing to excess fat intake [11, 26, 27]. Additionally, school wide practices supporting the consumption of high calorie, low nutrient foods have been positively associated with student BMI . Before modifications to the school food environment are successfully implemented, it may first be necessary to educate food service personnel on the relationship between competitive food availability and the nutritional quality of student's food choices. Additionally, schools must feel confident that providing healthful food choices will not adversely impact revenue, lunch participation rates, or school meal costs. Unfortunately, research in this area is limited and more work is needed before collaborative efforts addressing adolescent obesity through modifications to the school food environment can be successfully undertaken. Additional training regarding nutritional standards and what constitutes a 'healthy' item may be warranted. Education standards do not currently exist for food service personnel and, as a result, knowledge about nutrition and its related concepts varies widely . Establishing education standards seems critical to increasing foodservice personnel's awareness of the nutritional quality and health issues associated with the types and quantities of foods they serve and may go a long way toward ensuring a healthier school environment [28, 29].
Similar to the food service personnel, some principals felt that mandates for school wellness policies could be helpful, but most believed this was not the best approach to addressing adolescent obesity and would be largely ineffective without the proper assistance and resources. As a result, many principals viewed the wellness policy as a hassle and felt that future policies focused on the school environment and adolescent obesity would be more effective if they: a) were informed by educators who were experienced 'in the field;' b) provided adequate time and resources for schools to develop and carry out changes; c) lessened schools' responsibilities in other areas (e.g., academic achievement) and; d) reached beyond the school environment to address the foods/beverages available to students at restaurants and convenience stores located within close proximity to schools. Principal's suggestions are consistent with a recent statement released by the Society of Behavioral Medicine, which suggests that, although the Child Nutrition and WIC Reauthorization Act of 2004 is a positive step, future legislation must encourage schools to better incorporate evidence-based methods for promoting behavior change and provide schools with funding to adequately carry out and evaluate the effectiveness of initiatives .
Obtaining buy-in and removing barriers among principals and food service personnel are critical steps in efforts to change the school food environment. Relevant barriers, discussed by our sample and consistently mentioned as barriers in the literature, included the increased cost, perishable nature, and difficulty in obtaining healthy items, the possibility for decreased lunchtime participation and its potential impact on rising meal costs, the importance of ALC in supporting the food service program, low priority for health promotion activities due to time constraints and competing demands, and budgetary constraints that compel schools to find additional funding to support necessary programs [31, 32]. While several studies have demonstrated that pricing strategies increase the sale of healthy items (e.g., fresh fruit, baby carrots, low fat snacks) [33–35] and do not adversely impact revenue , the methods of these studies are difficult to translate or sustain in 'real world' settings. To obtain buy-in and support from school personnel, more practical strategies for addressing relevant barriers are needed. Strategies might include providing financial incentives for offering healthier items, working with vendors to make healthy items readily available at a lower cost, decreasing reliance on ALC by increasing federal reimbursement for the main lunch program, and educating personnel about how to make healthy, yet palatable changes to their existing offerings.
Personnel's reaction to legislative involvement in the school environment mirrors recent debate ignited by obesity-related public health laws. While advocates view obesity-related policy initiatives as a powerful instrument of public health, opponents see these measures as an infringement on freedom of choice . The perspective of the school personnel in this study represents yet another disconnect between government and public health officials and educators. Personnel had heard about the mandate but knew very little about the specific details of what it entailed. This raises concern about how policy level changes are communicated to school personnel and the degree to which legislation is taken seriously. Many seemed to disregard the legislation as 'yet another mandate being handed down by the government' or 'yet another thing schools are being told we have to do.' Others seemed to resent the authority imposed on them by federal and state government and expressed a desire for more input into the process. Given these reactions, the effectiveness of the mandate in creating a healthier school environment is called into question. As additional legislation is considered and proposed, it seems necessary to better engage school officials and equip them with the proper resources to successfully carry out proposed changes .
Two final points emerged that are worth noting. Almost universally, food service personnel stressed that ALC was intended as a supplement, not a replacement to the main meal. The programs in many schools were set up in this fashion (e.g., offered only snack-type items, opened only after students had gone through the main lunch line); however it is not known if this is how it was being used. More research is needed to establish student's ALC lunch patterns. In addition, there are some inherent problems with ALC being used as a supplement to the main meal. Specifically, previous research has shown that the items available from ALC are low in nutrients and high in fat, calories, and sugar [8, 9] and the availability of these items has been found to displace the selection of other healthful foods and adversely impact the quality of student's diets [11, 26, 27]. These findings are concerning and suggest that ALC items, regardless of whether consumed as a meal or as a supplement to a meal, provide excess calories and fat and may pose a threat to the overall healthfulness of student's diets. More research examining these associations is critical, as is the communication of the findings to school officials.
Finally, food service personnel stressed that vending was not a part of the food service program and, in general, they wanted little input into vending unless it interfered with main lunch or ALC purchases. Principals also seemed largely removed from the vending programs, raising questions about who provided oversight for vending in the majority of participating schools. In many cases, it appeared that decisions regarding what products to sell were left primarily to the vendors. Given that changes to the products available in school vending machines are a relatively simple, yet potentially fruitful way to facilitate healthier school environments, more effort should be devoted to identifying the appropriate personnel within schools and encouraging them to take a more active role in product selection for their vending programs.
A number of study limitations should be noted. First, the results provide an in-depth understanding of a relatively unexplored area, however the results may not generalize but rather may be transferred to similar groups and settings . Second, the study was not designed as a nested sampling frame, therefore we were unable parcel out differences between public and private schools, schools of varying sizes and grade levels (i.e., elementary and middle schools), and those located in predominately rural, suburban, or urban areas; all characteristics that may influence the results. Because of our focus on potential obesogenic factors, we excluded schools with limited vending and ALC programs. Despite limited competitive food sources, excluded schools had higher obesity rates, likely because they were smaller and poorer. More research is needed to examine potential school-, familial-, and community-level factors contributing to obesity in these resource poor areas. Third, the present study represents the views of high school principals and food service personnel; it does not represent the opinions of teachers, staff, or other administrators (e.g., superintendents, assistant principals).