Analyzivng Demand for Customized Obesity Prevention and Management Across Adult Age Groups Using Focus Group Interview

Abstract

With the increasing obesity rates, many studies on obesity prevention and management have been implemented. However, few studies focused on obesity in adulthood and different perceptions of obesity between life cycles. Thus, this study aimed to investigate the demand for customized obesity prevention and management (OPM) strategies across adult age groups. Focus group interviews were conducted to gather insights from three age groups: young adults (20-34 years), middle-aged adults (35-49 years), and seniors (50-64 years). A total of 17 participants took part in the study, with 5 participants in Group 1, 6 participants in Group 2, and 6 participants in Group 3. Thematic analysis and the use of NetMiner version 4.4.3 facilitated data categorization and scrutiny. The study employed qualitative methods to explore perceptions of obesity and preferences for personalized OPM strategies among participants. Diverse perspectives on obesity as a health threat were found among the age groups. While all stressed the importance of personalized OPM, preferences for strategies varied. Diet and exercise combination emerged as a common preference. This study highlighted the need for customized OPM approaches aligned with age-specific preferences.

• What do we already know about this topic?

• Previous research has primarily focused on childhood obesity and generalized approaches to prevention, leaving a gap in understanding age-specific perceptions and preferences for obesity management among adults.

• How does your research contribute to the field?

• Through focus group interviews across age groups, this study reveals varied perceptions of obesity and emphasizes the necessity for personalized prevention programs, advocating for age-specific strategies that correct misconceptions and integrate preferences for diet and exercise.

• What are your research’s implications toward theory, practice, or policy?

• The research emphasizes the importance of tailoring Obesity Prevention and Management (OPM) strategies to individual preferences and health conditions, highlighting the need for policymakers to integrate age-specific perceptions, ensuring effective and adaptable program implementation.

Introduction

The coronavirus disease 2019 (COVID-19), a worldwide pandemic, has impacted daily lifestyles, including eating habits. ¹ With changes in eating habits, the rate of obesity has increased in both adults and children.^{2 -4} Obesity is a key contributor to the global burden of disease ⁵ and is a major risk factor for morbidity and mortality from various chronic diseases.^6,7 Various obesity prevention and management (OPM) studies have been implemented. ⁸

Approaches for effective and successive obesity management should be tailored to lifecycles.^9,10 Adulthood (between 19 and 64 years old) has the longest life cycle, and overall health management in this period is important. Therefore, OPM in young adulthood is crucial to prevent obesity in the elderly. However, most obesity management and prevention programs have focused on children or the elderly,^11,12 not on young and middle-aged adults. Thus, a customized OPM model according to life cycle, individual preferences, and health conditions requires development.

OPM requires individual behavioral changes, which derive from perceptions, ¹³ therefore management of weight bias and stigma should precede interventions for OPM. ¹⁴ In addition, as there is interaction between self- and public stigma, ¹⁵ individuals in different age groups will perceive obesity differently. However, few studies have analyzed perceptions of obesity. Thus, we conducted focus group interviews (FGIs) to confirm and compare perceptions of obesity by life cycle-based age groups.

Methods

Study Design

We conducted semi-structured FGIs for qualitative data collection. FGI is a useful qualitative method that can generate data through interaction^16,17 and is used to understand the perspectives of participants through discussion. ¹⁸ During the interview, participants answered the facilitator’s questions, and simultaneously interacted with each other. ¹⁹ Through this conversation and interaction, participants explored and clarified their individual and shared perspectives. ²⁰ FGI is used to explore views on health issues, programs, interventions, and research. ¹⁸ .

Recruitment

We planned three FGIs according to life cycles, because different OPM designs by life cycle should be based on each life cycle’s demands and perceptions and 3 to 5 groups would be adequate for saturation.^9,10,21 According to a previous study that recommended a group of 4 to 12 participants for FGIs, ²² we recruited 5 to 7 participants for each interview group through a public health center and local university advertisements, all of whom participated voluntarily. When composing a group, it is important to consider whether participants share common characteristics so that interaction may occur at an optimum level. ¹⁷ Participants were eligible if they were 20 to 64 years old and lived in Uijeonbu-si, Gyeonggi-do, South Korea. Individuals who did not meet these inclusion criteria and were unable to conduct the interview or express their personal experiences and thoughts were excluded. We divided the interview groups according to age, considering the life cycle of adulthood. Group 1, the young adult group, consisted of participants aged 20 to 34 years. Groups 2 (middle adulthood) and 3 (senior adulthood) consisted of participants aged between 35 and 49 years and between 50 and 64 years, respectively.^23,24 This study was approved by the Institutional Review Board of Shinhan University (IRB No. SHIRB-202207-HR-168-01).

Focus Group Interviews and Survey

Preparation in advance

Data on participants’ characteristics such as age, sex, height, weight, job, smoking status, alcohol frequency, housing type, and diagnosed chronic disease status were collected using a Google online survey prior to the interview (Appendix 1). In addition, interview questions were delivered beforehand to help participants prepare for the interview (Appendix 2). Pre-questionnaires were developed referring to previous literature regarding obesity management programs (Appendix 3). Most studies have targeted dietary management and physical activity, thus, we also collected basic information regarding dietary management and exercise experiences. Interview questions were developed to determine how each group perceived obesity and its management (Table 1).

Table 1.

Questionnaire for Interview.

Domain	Question	Question content
Perception of obesity	1-1	What are your usual thoughts on obesity?
Perception of obesity	1-2	What do you think about social perceptions of obesity?
Perception of obesity management	2-1	What are your usual thoughts on obesity management?
Perception of obesity management	2-2	How do you think obesity management should be conducted?

Interviews

The FGIs were conducted in January 2023 in a meeting room located at a university affiliated with one of the researchers. Three FGI sessions, each conducted once per group, totaling three interviews, were based on the life cycle-based age groups as defined earlier. The interviews were conducted according to a previous study ²⁵ and the interviews were recorded using mobile phone recorders and transcribed. Before conducting the FGIs, the researcher (M.K.) explained the purpose of the study and obtained written informed consent from the participants. To maintain the confidentiality of the participants, interviews were conducted by referring to individuals by color, such as red or blue. Each interview session lasted 110 min including 10 min breaks to check the fatigue of the participants.

Two topics were discussed in the FGIs as described in Table 1: (1) perception of obesity and (2) perception of obesity management (Table 1). After every question, the researcher (M.K.) debriefed discussion to summarize answers and ask whether there are additional opinions. Discussions continued until the theoretical saturation point, when no new opinions were found for each topic.

Analysis

The FGI data were analyzed using recorded audio and transcribed text files. We categorized and analyzed the data according to thematic analysis. ²⁶ It is a method for identifying, analyzing, organizing, describing, and reporting themes found within a data set. ²⁷ Three researchers read and categorized themes independently, and then re-categorized them into seven discussions. NetMiner version 4.4.3 (Cyram Inc., Seongnam, Korea), a program widely used for network analysis in various disciplines, was used for graphical data visualization.

Results

The participant characteristics in the three groups were shown in Table 2. The mean age of Group 1, which included five participants, was 22.89 years (standard deviation [SD]: 3.11), the mean age of the six participants in Group 2 and Group 3 was 36.67 years (SD: 6.35) and 53 years (SD: 1.79), respectively. In Group 1, 40% of the participants were male, whereas the proportion of males in Groups 2 and 3 was 50%. The average BMIs of Group 1, 2, and 3 were 23.55kg/m² (SD: 2.64), 25.28kg/m² (SD: 2.98), and 25.21kg/m² (SD: 3.63)kg/m², respectively. In Group 2, participants with hypertension accounted for 16.7%, in Group 3 participants with hypertension, diabetes, and hyperlipidemia accounted for 33.3%, 50%, and 33.3%, respectively. In Group 1 and 3, around 60% of participants tried to manage diet, whereas in the Group 2, 100% of participants tried to manage diet.

Table 2.

Demographic Characteristics of Participants.

	Group 1 (N = 5)	Group 2 (N = 6)	Group 3 (N = 6)
N (%) or mean (standard deviation)
Age	22.89 (3.11)	36.67 (6.35)	53.00 (1.79)
Sex
Male	2 (40.0)	3 (50.0)	3 (50.0)
Female	3 (60.0)	3 (50.0)	3 (50.0)
Job
Resident	1 (20.0)	0 (0.0)	3 (50.0)
Faculty	0 (0.0)	6 (100.0)	3 (50.0)
Student	4 (80.0)	0 (0.0)	0 (0.0)
Body Mass Index	23.55 (2.64)	25.28 (2.98)	25.21 (3.63)
Normal (<25 kg/m2)	4 (80.0)	2 (33.3)	2 (33.3)
Obese (≥25 kg/m2)	1 (20.0)	4 (66.7)	4 (66.7)
Smoking status
Never	2 (40.0)	6 (100.0)	3 (50.0)
Past-smoker	3 (60.0)	0 (0.0)	2 (33.3)
Current-smoker	0 (0.0)	0 (0.0)	1 (16.7)
Alcohol frequency
Never	0 (0.0)	1 (16.7)	0 (0.0)
Often	2 ( 40.0)	1 (16.7)	2 (33.3)
Frequent	3 (60.0)	4 (66.7)	4 (66.7)
Housing type
One-person household	1 (20.0)	2 (33.3)	0 (0.0)
Living with family	2 (40.0)	4 (66.7)	6 (100.0)
Living with a friend	2 (40.0)	0 (0.0)	0 (0.0)
Hypertension
Yes	0 (0.0)	1 (16.7)	2 (33.3)
No	5 (100.0)	5 (83.3)	4 (66.7)
Diabetes
Yes	0 (0.0)	0 (0.0)	3 (50.0)
No	5 (100.0)	6 (100.0)	3 (50.0)
Hyperlipidemia
Yes	0 (0.0)	0 (0.0)	2 (33.3)
No	5 (100.0)	6 (100.0)	4 (66.7)
Efforts to manage body weight
To lose	4 (80.0)	4 (66.7)	5 (58.3)
To gain	1 (20.0)	0 (0.0)	0 (0.0)
To maintain	0 (0.0)	2 (33.3)	1 (16.7)
N/A	0 (0.0)	0 (0.0)	0 (0.0)
Efforts to manage diet
Yes	3 (60.0)	6 (100.0)	4 (66.7)
No	2 (40.0)	0 (0.0)	2 (33.3)

Group 1: the young adult group, consisted of participants aged 20 to 34 years.

Group 2: the middle adulthood group, consisted of participants aged 35 to 49 years.

Group 3: the senior adulthood group, consisted of participants aged 50 to 64 years.

Table 3 showed the overall structural framework for extracting the participants’ perspectives on obesity using the terms presented in each group’s recorded interviews. We classified the perception of obesity into the following categories: (1) obesity and (2) OPM. Furthermore, the perspective of obesity was classified into two categories: (1) individual and (2) sociological perspectives. Perspectives on OPM were classified into two categories: (1) OPM and (2) method for OPM.

Table 3.

Mapped Results of Each Theme.

Theme	Sub-theme	Categories
Perspective on obesity	Individual perspective on obesity	Misperceptions of obesity diagnosis
		Limitations of obesity diagnosis
		Negative view of obese people
		Neutral view of obese people
	Sociological perspective on obesity	Recognize body shape as a criterion for obesity evaluation
		Recognize that obesity rates have skyrocketed since COVID-19
		Body shape evaluation standards have been raised after COVID-19
		Threat to health
		Result of habits
		Body shape evaluation standards have been raised due to celebrities on TV
Perspective on obesity prevention and management	Perspective on obesity prevention and management	Recognize obesity prevention as part of self-management
		Recognize that exercise is a way to manage body shape
		Recognize as an opportunity for goal setting
	Method for obesity prevention and management	Customized obesity management
		Weight loss
		Integrated type (exercise and diet)
		Diet instead of exercise
		Exercise instead of diet

Figure 1 depicted the common and differing perceptions of obesity and its management among the three groups. All three groups agreed that it was important to “customize” obesity management. Additionally, they had a negative view of people with obesity and recognized obesity prevention as part of self-management.

Figure 1.

Mapped categories of each theme depending on the group. Each group was symbolized with red circles, and two themes—perspective on obesity and perspective on obesity prevention and management—were symbolized with green and purple squares, respectively. Bolded squares were included in sub-themes—individual perspective on obesity and obesity prevention and management. G1 = Group 1 (the young adult group, consisted of participants aged 20-34 years). G2 = Group 2 (the middle adulthood group, consisted of participants aged 35-49 years). G3 = Group 3 (the senior adulthood group, consisted of participants aged 50-64 years).

“I think it is okay to correct eating habits and life patterns first, and then do an exercise program.” (Group 1, Participant 1)

“I hope someone can tell me the optimal exercise method for each person.” (Group 2, Participant 1)

“I think it would be nice to have some kind of customized management by dividing the type of obesity into subdivisions.” (Group 3, Participant 1)

Group 1 pointed out that after COVID-19, the obesity rate increased, and the standard for body shape was raised. The participants also stated that diet and exercise should be integrated to prevent and manage obesity.

“When the term ‘quarantine 15’ appeared after COVID-19 started, I thought it was a bit serious about obesity” (Group 1, Participant 2)

“In the pandemic situation caused by COVID-19, non-face-to-face activities, such as social media activities, have increased, and more people have taken pictures of their body profiles and posted them. I think because of that, the standards for people’s body shape have been raised and there are a lot of evaluations of each other’s appearance.” (Group 1, Participant 1)

“A lot of people around me are having personal training, and they said that it is very effective if we manage our diet and exercise together.” (Group 1, Participant 3)

In comparison, Groups 2 and 3 stated that obesity was a threat to health and had misperceptions of the obesity diagnosis. As a method of OPM, Group 2 preferred a controlled diet instead of exercise, while Group 3 preferred exercise instead of diet.

“I think my concerns about my health have risen a bit. In fact, people with obesity also have many co-morbidities.” (Group 2, Participant 1)

“Obesity is bad for our health in general, and I think obesity is a real enemy.” (Group 3, Participant 2)

“Wouldn’t it be more effective to exercise if you control what you eat? It would be nice to have a salad or light meal.” (Group 2, Participant 1)

“I find joy in eating. Don’t tell me what to eat. I am going to exercise on my own. I will go hiking and play golf. So don’t say anything to me. I eat what I want to eat on the weekends because this is my own happiness.” (Group 3, Participant 3).

Discussion

We conducted focus group interviews to determine perceptions of obesity and obesity management programs among adult age groups. FGIs were conducted three times separately for each age group, with participants in young, middle, and senior adulthood. Their perceptions of obesity were divided into two categories: individual and sociological perspectives and their perceptions of OPM were classified into two categories: perspective and method for it.

All three groups commonly pointed out a negative view of people with obesity and recognized obesity prevention as part of self-management. Many other cross-sectional surveys have shown weight bias or obesity prejudice.^28,29 Obesity prejudice has shown an increasing rate of discrimination, ³⁰ and experiences of obesity discrimination among people with obesity are associated with adverse mental health.^31,32 The reason for stereotypes and prejudice against people with obesity is that society regards people with obesity as responsible for their weight because of their laziness, lack of willpower, and overeating.^28,29,33 Our interviewees in all age groups also showed a similar stigmatization of obesity, therefore we need to consider the mental health of people with obesity when planning strategies for their health. Additionally, obesity prevention programs should be cautious about not using prejudiced or biased terms to describe obesity.

Interviewees in Group 1 indicated that the standards for body shape evaluation were raised after COVID-19. Social media use increased after the pandemic ³⁴ and has become prominent among the younger generation. ³⁵ Increase in social media use could impair body perception. ³⁶ The strict criteria for body weight, which was mentioned only among Group 1, is one of the incorrect perceptions of obesity; therefore, when we plan OPM programs, the contents need to correct faulty thinking, helping participants to view their condition realistically.

Unlike Group 1, Group 2 and 3 viewed obesity as a health threat. It is a major risk factor for various chronic diseases ⁶ including cardiovascular diseases and metabolic disorders.^7,37 Aging also leads to serious health problems and is associated with the risk of obesity. ³⁸ Group 2 and 3 consisted of older adults; therefore, they perceived obesity as a health problem and connected their health conditions with body weight. However, the risk of obesity in young adulthood has rarely been estimated,^11,12 therefore Group 1 participants had low perceptions of obesity as a health problem. Thus, when treating obesity in middle or senior adulthood, OPM programs need to consider health indices, such as blood lab measurements, as a strategy for effective program operations.

From the perspective of the OPM method, all three groups stated that customized obesity management is important. Individuals have their own action plans, preferred health management methods, and goals for self-management. ³⁹ Adherence to a management program plays a vital role in the positive effects of the program; therefore, it is crucial to make OPMs adhere to each person’s customized preferences for a better outcome. ⁴⁰ Participants in Group 1 preferred managing diet and exercise simultaneously to prevent and manage obesity, unlike those in the other 2 groups. A qualitative study of 8 university students in the United States identified lack of exercise and unhealthy dietary habits as healthy weight barriers. ⁴¹ Respondents in the qualitative study said that maintaining a healthy diet was difficult, and that they had limited knowledge about healthy food. Both lifting weights and regular exercise were important for the respondents, but maintaining proper exercise was also challenging. Young adults have difficulties maintaining their exercise schedules and managing or sourcing a healthy diet, which may contribute to their preferences for both diet and exercise for OPM.

One of the major differences between Group 2, 3 and Group 1 was their preference for the OPM method. Participants in Group 2 preferred diet management to exercise, and participants in Group 3 preferred exercise to meal management. A cross-sectional study in North America showed lower physical activity levels in the 50 to 54 year old group, and reported that “being busy” was more common in middle-aged adults.^42,43 Participants in Group 2 need to work and simultaneously raise their children, therefore being busy and lacking time to exercise may make them prefer diet to exercise.

Regular exercise and the avoidance of a sedentary lifestyle are encouraged to prevent and manage health conditions. ⁴⁴ All Group 3 participants viewed obesity as a health threat and showed a higher incidence rate of type 2 diabetes and hypertension (50% of participants had diabetes and 33.3% had hypertension; Table 1) as chronic disease incidence rates increase with age. ⁴⁵ This may contribute to their preference for exercise over diet, as they are advised to exercise regularly to prevent and manage chronic diseases. ⁴⁴ Using the preferred method for obesity management increases adherence to management programs, ⁴⁶ thus, OPMs should consider these preferences as a strategy for customized and life-cycle-based recommendations.

This study has some limitations. As our interview participants were residents of specific provinces in South Korea, their perceptions of obesity may differ from those of other countries or ethnicity/race groups. Therefore, caution should be exercised when generalizing our results to other populations. Further studies should be conducted in various regions, including rural and urban regions, children, people over 65 years of age, and ethnicity/race groups. Furthermore, since the majority of participants had a normal BMI, their perspectives on OPM may differ from those of individuals with obesity. Nonetheless, the insights provided by participants with normal BMI remain valuable, as managing the body weight of individuals within the normal range is also imperative from an obesity management perspective. However, this was the first study to analyze perceptions of obesity, and the OPM program depends on adult age groups. We determined common and different perceptions between life cycle-based age groups. Our findings can be utilized when OPM programs or policies are implemented considering life-cycle-specific perceptions of obesity and preferences to maximize adherence to programs and their positive effects.

Conclusion

We investigated perceptions of obesity and found that successful OPM programs depend on adult age groups. All three groups agreed that personalized obesity management is crucial and recognized negative perceptions toward obese individuals and obesity prevention as part of self-management. In addition to common perceptions, the preferred methods for OPM appear to vary depending on the life cycle. When implementing an OPM program or policy, individual and sociological perspectives on obesity must be considered, along with suitable, personalized, and preferred management methods for OPMs based on adult age groups.