Abstract
Obesity among children and adolescents is a serious global public health problem. It can lead to obesity in adults, decreased healthy life expectancy, and increased medical costs. Therefore, a national-level intervention, prevention, and active management of obesity are imperative. Current obesity prevention and management projects for children and adolescents are temporary, segmented, and duplicative, with a notable lack of efficient government-led program. In this study, we uncovered the current status of obesity prevention and management projects for children and adolescents, along with problems associated with it from multifaceted perspectives. A survey and in-depth interviews were conducted with fieldworkers and experts. Based on the results of this study, we suggested the following policy directions.
Keywords: Child, Adolescent, Obesity (prevention), Intervention, Community
Key messages
➀ What is known previously?
Currently, various child and adolescent obesity prevention and management projects and policies are being implemented in the Republic of Korea. However, these projects are often temporary, segmented, and duplicative, indicating scope for improvement.
② What new information is presented?
Lack of awareness among parents and students about obesity prevention and management projects and inadequate cooperation between institutions are major challenges encountered during project operations. Schools are the main activity spaces for students; therefore, school-centric programs must be implemented to facilitate such projects. Additionally, active cooperation from related organizations in the local community is required.
➂ What are implications?
To implement obesity prevention and management projects for children and adolescents efficiently, it is necessary to prepare a national-level concrete action plan. Smooth operations and cooperation within the local community become possible only when this is done in advance.
Introduction
The recent rise in the prevalence of child and adolescent obesity, especially that of class 2 and higher obesity, following the coronavirus disease 2019 pandemic has become one of the most serious public health concerns, and its management is recognized as a critical factor in preventing cascading socioeconomic problems beyond simple maintenance of health [1]. Factors that influence child and adolescent obesity are highly complex and dependent on the educational and family environment, which therefore require active social interventions because food intake and physical activity are not aspects of life in which children and adolescents can directly participate [2].
In particular, obesity in children and adolescents has a high probability to continue toward adulthood and is associated with chronic diseases such as diabetes, hypertension, dyslipidemia, and non-alcoholic fatty liver disease in young adulthood. This not only causes suffering throughout the individual’s long life cycle but also social problems such as psychiatric problems and difficulties with friendships [3]. This phenomenon is exacerbated in relatively low-income and vulnerable populations [4]. According to the 2019 Obesity Fact Sheet (Korean Society for the Study of Obesity, 2019), the prevalence of adult obesity by socioeconomic level tends to increase with lower education level, and rural areas have a higher prevalence of obesity than urban areas. This indicates that the risk of obesity is higher among socioeconomically disadvantaged groups and requires national-level management [5].
Currently, although the national government and local governments operate various obesity prevention programs, they are temporary and overlapping, lacking an efficient system at the governance level. This makes the evaluation of their effectiveness and management difficult [6-8]. This study aims to identify the status and current problems of prevention and management projects regarding child and adolescent obesity from various aspects and suggest policy measures to complement them.
Methods
1. Quantitative Survey
1) Survey of obesity prevention and management projects for children and adolescents
To determine the current state of development for community-based obesity and control programs and implementation systems nationwide, a quantitative survey was administered to practitioners and providers involved in project delivery at public health centers and elementary and middle schools. The survey employed a six-step process: Step 1) Review of domestic and international literature → Step 2) Development of preliminary survey items → Step 3) Feasibility study → Step 4) Preliminary survey → Step 5) Selection of final survey items and survey implementation → Step 6) Analysis of results and feedback.
To ensure the survey’s validity, eight experts from academia, schools, and public health centers reviewed the items. The survey was then conducted nationwide in collaboration with the Korea Disease Control and Prevention Agency and the Korean Health Teachers Association.
The survey targeted practitioners and project providers at 6,163 elementary schools, 3,258 middle schools (estimated to be about average workforce 2.4 people, according to the 2022 Education Statistics Annals), and 258 public health centers (estimated to be about average workforce 2.8, according to the 2021 Status of Local Healthcare Organizations) nationwide, for an estimated population of 22,946 people. A total of 577 individuals completed the survey (508 from schools and 69 from public health centers), representing a response rate of 2.3% for schools and 9.5% for public health centers.
2. Qualitative Survey
A qualitative survey was conducted with two distinct groups: project providers and experts. Project provider were interviewed about the specific reasons behind project operation difficulties and practical solutions for facilitate. In contrast, experts offered insights into the system’s macro-level direction, including strategies to improve governance and policy approaches.
1) In-depth interviews with the project providers of obesity prevention and management projects for children and adolescents
In-depth interviews were conducted with representatives from various organizations. This included personnel from the Ministry of Education, the Office of Education, elementary and middle schools, the Center for Child-Care Foodservice Management, and universities participating in community engagement projects within the education sector. Additionally, representatives from public health centers known for their active participation in obesity prevention initiatives or strong responses to the quantitative survey were interviewed in the health sector. A total of 18 organizations participated, geographically distributed across seven locations in Seoul, five in the Incheon and Gyeonggi-do, one each in Gangwon-do and Chungcheong-do, and two each in Jeolla-do and Gyeongsang-do. The selection considered both regional size and city population.
2) Expert opinion survey
An expert opinion survey was conducted using a mixed-method approach. This involved both written responses and in-person interviews, tailored to individual circumstances. The survey included participation from 14 experts with diverse backgrounds: five clinicians, three education specialists, four public healthcare experts, and two specialists in related fields. Their insights focused on program improvement strategies and future development directions.
Results
1. Survey Results of Obesity Prevention and Management Projects for Children and Adolescents
1) Project status and project provider characteristics
The child and adolescent obesity prevention project at each school is typically run by a team of around 2.4 people, and operates with an average annual budget of KRW 1.91 million (Table 1). Notably, 33.3% of respondents reported no separate budget allocated for this initiative. The primary funding source comes from the Ministry of Education and the Office of Education. School personnel involved in these projects are predominantly female (85.8%), with an average age of 41.8 years. School nurses make up the majority of respondents (81.1%).
Table 1. Number of main participants and budget in the project.
| Contents | Average | Median | Standard deviation | Minimum | Maximum | |
|---|---|---|---|---|---|---|
| Number of main participants (people) | School | 2.4 | 2.0 | 3.1 | 1.0 | 41.0 |
| Public health center | 2.8 | 2.0 | 1.6 | 1.0 | 10.0 | |
| Budget (unit of 10,000 won) | School | 191.0 | 150.0 | 213.1 | 5.0 | 2,200.0 |
| Public health center | 1,294.9 | 700.0 | 1,510.5 | 50.0 | 8,000.0 | |
Public health centers generally have a larger team size of approximately 2.8 people managing child and adolescent obesity prevention projects. However, the annual budget varies significantly across centers and projects, ranging from KRW 500,000 to KRW 8,000, with an average of KRW 12,950,000 (Table 1). The Ministry of Health and Welfare and local governments are the main funding sources. Similar to schools, the workforce at public health centers involved in these projects skews female (84.1%). The average age is 36.3 years, and the range of professions is more diverse than that of schools. Nurses (36.2%) form the largest group, followed by exercise expert (14.5%) and dietitians (11.6%).
2) Purpose and content of project operations
Schools primarily focused their obesity prevention programs on prevention (82.9%), intervention (73.2%), and awareness-raising (29.3%). The program content typically included educational components (91.5%), followed by counseling (48.4%), monitoring (47.8%), and evaluation (20.7%). In contrast, public health centers prioritized prevention (95.7%) and awareness-raising (58.0%) over intervention (42.0%). Their programs also included elements of education (94.2%) and monitoring (63.8%). However, public health centers offered a wider range of support by providing supplies (30.4%) and counseling (29.0%) compared to schools (Table 2).
Table 2. Main operational purpose and content of the project.
| Contents | School | Public health center | |
|---|---|---|---|
| Purpose | Fact-finding survey | 55 (10.8) | 5 (7.2) |
| Improving awareness | 149 (29.3) | 40 (58.0) | |
| Obesity prevention | 421 (82.9) | 66 (95.7) | |
| Obesity intervention | 372 (73.2) | 29 (42.0) | |
| Performance | Evaluation | 105 (20.7) | 19 (27.5) |
| Consulting | 246 (48.4) | 20 (29.0) | |
| Education | 465 (91.5) | 65 (94.2) | |
| Monitoring | 243 (47.8) | 44 (63.8) | |
| Provision of goods | 81 (15.9) | 21 (30.4) | |
| Medical treatment linkage | 16 (3.1) | 1 (1.4) | |
Unit: n (%). (duplicate response).
3) Project linkage level
A five-point scale assessed the perceived importance and actual level of collaboration between various entities involved in school-based obesity prevention projects. Importance was determined by the combined percentage of respondents who rated collaboration as “important” and “very important.” Similarly, the actual level of collaboration was measured by summing the percentage who answered “sufficient” and “very sufficient.”
School personnel identified school-to-school collaboration as the most crucial (90.0%), followed by collaboration with public health centers (80.3%), community sports facilities, and school-management organizations (72.6%). However, the reality of collaboration differed. While most common among schools (60.0%), collaboration with public health centers (27.6%), and healthcare organizations (18.3%) fell short of perceived importance. Notably, both school-public health center collaboration and collaboration with physical education facilities displayed a significant gap between perceived importance and actual levels (Figure 1).
Figure 1. Comparison of the importance of inter-institutional cooperation and actual connectivity (school to other institutions).
Public health center personnel mirrored the importance placed on school collaboration (97.1%), followed by collaboration with other public health centers (89.9%) and community sports facilities (69.6%). However, the actual collaboration patterns differed slightly. The most frequent collaboration occurred between public health centers themselves (75.4%), followed by collaboration with schools (63.8%), and community sports facilities (33.3%) (Figure 2). Similar to schools, public health center personnel reported a disconnect between the perceived importance of collaboration with schools and physical education facilities and the actual level of collaboration, emphasizing the gap despite its recognized value.
Figure 2. Comparison of the importance of inter-institutional cooperation and actual connectivity (public health center to other institutions).
2. Results of In-depth Interviews with the Project Providers of Obesity Prevention and Management Projects for Children and Adolescents
1) Perception and direction of projects
In terms of active obesity prevention interventions, schools prioritized educational interventions, emphasizing the need for obesity management education, increased time for physical activity through adjustments to extra-curricular schedules, and the creation of a supportive school environment. In contrast, public health centers focused on monitoring and practice-based interventions, highlighting the importance of regular monitoring, providing support for physical activity and promoting healthy nutrition practices, even offering incentives to encourage project participation.
Despite these differing approaches, both schools and public health centers acknowledged the critical role of obesity prevention programs and the seriousness of childhood obesity. Additionally, both the education and health sectors agreed that schools should be a central player in these efforts.
2) Project linkage status
In terms of intra-institution collaboration, schools reported difficulty collaborating routinely unless designated as part of special programs like “Research Schools” or “Health Dream Schools”. Conversely, public health centers found collaboration within teams to be readily achievable but acknowledged challenges in collaborating between departments. These findings indicate that both schools and public health centers struggle to maintain collaboration across different departments within their organizations.
External collaboration also presents distinct challenges. Schools primarily responded to external requests for program publicity, suggesting a more reactive approach. In contrast, public public health centers proactively delivered programs at various locations such as daycare centers, schools, and community child centers.
3) Challenges of operating the projects
Both school and public health center practitioners identified a lack of willingness and awareness among parents and students as a significant barrier to program implementation. Specifically, they reported low levels of awareness regarding the seriousness of obesity among the target audience and concerns about potential stigmatization and negative impacts on peer relationships if students participated in the program.
Another common challenge was the lack of specialized training materials and project operation manuals. This resulted in individual project providers taking on the primary responsibility for project planning.
Schools emphasized the lack of budget and professional manpower as obstacles to operating an education-centered prevention system. This suggests a need for additional resources to support effective program delivery within schools. Public health centers reported difficulty recruiting participants without the active cooperation of schools, as this is where students spend a significant amount of time.
4) Project facilitating factors and important considerations
Schools prioritized the following factors as crucial for project success: awareness among parents and children, staff training, community engagement, publicity, budget, and facility infrastructure. In contrast, public health centers placed greater emphasis on publicity, facility infrastructure, budget, and policy and institutional arrangements.
Schools highlighted the importance of addressing the quality of students’ home environments, motivating both children and caregivers for program participation, and acknowledging the limitations of implementing programs solely within public health centers. Ensuring the long-term viability of the projects and having clear guidelines and educational materials were also seen as major concerns for schools.
Public health centers, on the other hand, emphasized creating programs that were appealing to children. They also saw cooperation from the Ministry of Education and the Office of Education as critical, along with implementing projects directly within schools. Establishing strong local connections and having access to professional organizations for guidance were viewed as beneficial by public health centers.
3. Expert Opinion Survey Results
1) Opinions on operational plans for community-based obesity and chronic disease prevention
An expert in public healthcare projects emphasized the critical need for a central coordinating body, a control tower, to oversee and facilitate community-based child and adolescent obesity prevention initiatives. The expert further highlighted the importance of increasing physical activity opportunities within schools, given the significant amount of time children and adolescents spend there. This suggests a shift toward prioritizing school-based initiatives alongside community efforts. For successful implementation, it is crucial to focus community resources and budgets on supporting schools while fostering strong collaboration with local public health centers and other community organizations.
2) Challenges of operating the projects
Experts identified several key challenges hindering child and adolescent obesity prevention projects. First, participants and their parents often lacked the necessary awareness and motivation to actively engage in the programs. Second, the Office of Education and Education Support Centers, which manages school life, did not prioritize child and adolescent obesity prevention as a high-level concern. Finally, the dualized system of the Ministry of Education and the Ministry of Health and Welfare created inefficiencies, hindering the integration of projects within a unified framework.
3) Practical approaches to community engagement for obesity prevention and management projects for children and adolescents
Respondents acknowledged the difficulty of coordinating child and adolescent obesity prevention and management projects by relying on the commitment of one of the two organizations, the local government, or the Office of Education. They emphasized that effective program delivery hinges on projects that leverage the unique strengths and roles of each organization.
Respondents highlighted the critical need to elevate child and adolescent obesity prevention and control to a higher policy priority. This could involve increased government support and the implementation of incentive programs to encourage participation. Second, the suggestion to increase physical activity and exercise opportunities within schools was recognized as important, given the significant time students spend there. Finally, the need for increased social awareness regarding the seriousness of child and adolescent obesity was also emphasized.
Discussion
This study aimed to provide evidence-based support for local governance in planning and implementing child and adolescent obesity prevention projects and policies. It sought to gain a comprehensive national understanding of the current state of these programs in public health centers and schools (elementary and middle schools) across the country, moving beyond the limitations of focusing on a few regions or a small number of programs.
Schools generally target the entire student population rather than identifying individuals for intervention. This approach may have been influenced by concerns over stigmatization due to the labeling of obese children. While both inter-Institution and inter-professional collaboration was recognized as highly important, the study found disappointingly low levels of actual collaboration in both areas.
Analysis of the reasons behind this low collaboration included low openness to collaboration with other organizations, the burden of organizing extracurricular activities, and a lack of flexibility in adapting external plans to align with the school’s yearly schedule.
Project operation challenges identified included difficulties in carving out time for project activities outside of regular school hours, limitations in developing new and engaging program content, and a lack of active participation from students. This highlights the importance of not only project provider commitment, but also the willingness of participants to actively engage.
Similar to schools, public health center programs most often target the entire child population, regardless of individual obesity levels. The large variation in project budgets across centers may indicate that the intensity of intervention varies depending on the funding organization’s interests, rather than a standardized approach based on needs. To address this issue, it is recommended that project budgets be allocated proportionally to the size of the region and the number of children and adolescents it serves. Additionally, a re-evaluation is necessary to ensure programs designed specifically for children and adolescents are available and appropriately tailored to their needs, as many existing obesity prevention programs primarily target adults.
The current practice of evaluating program effectiveness solely through changes in physical development deserves review. Many programs focus primarily on educational activities, and these may not necessarily translate directly to immediate physical changes. Evaluation should consider a broader range of metrics beyond just physical development. Furthermore, rather than simple pre- and post-program Body Mass Index (BMI) comparison, it is recommended to continuously track the change in percentile BMI by age using pediatric growth charts. This provides a more accurate picture of program effectiveness by taking into account continuous growth patterns in children and adolescents.
This study revealed a significant gap between the perceived importance of collaboration, both intra-Institution and inter-Institution, in child and adolescent obesity prevention projects, and the actual level of collaboration achieved. This suggests that obstacles hinder the implementation of collaborative efforts despite their acknowledged value.
Interview results indicated that a strong perception of collaboration activities as extra work was a major barrier. Collaboration was more likely to occur when driven by external mandates, volunteer motivation, or genuine organizational interest. At the community level, the success of linkages and collaborations appears to be significantly influenced by the interest and engagement of guardians and households. These findings highlight the need for policy strategies that address these challenges.
To strengthen collaboration, policy strategies are needed to actively engage guardians and households at the central level. Developing mechanisms to incentivize and mobilize community organizations can further strengthen collaborative efforts.
While various government policies target childhood and adolescent obesity in the Republic of Korea (ROK), their implementation often occurs in a fragmented manner depending on the central authority involved. Given that home and school are the primary environments for children and adolescents, establishing an efficient linkage system among relevant authorities is crucial.
This calls for a more comprehensive policy and network-building strategy at the governance level. Efforts should extend beyond simply expanding human resources and developing project programs. A clear national goal for preventing child and adolescent obesity should be established. To achieve this goal, a comprehensive national strategy is needed, encompassing elements such as financial support, legal and institutional reforms, and a well-coordinated system across all levels of the central government (Figure 3) [9].
Figure 3. Proposal of essential elements for child and adolescent obesity prevention project.
Data from the article of McGlashan et al. (Sci Rep 2019;9:12599) [9].
This study aimed to translate valuable insights from a nationwide field survey of child and adolescent obesity prevention and management projects into actionable policy directions. Unlike previous research limited to specific regions or smaller samples, this study provides a comprehensive national perspective. It examines the current status of programs in public health centers and schools (elementary and middle schools), and gathers in-depth feedback from various stakeholders involved. The findings presented here are expected to significantly impact the implementation of obesity prevention and management policies for children and adolescents in ROK. Ultimately, this knowledge can contribute to a reduction in child and adolescent obesity rates and promote overall health improvements.
Acknowledgments
None.
Funding Statement
Funding Source: This research was supported by a grant from the Korea Disease Control and Prevention Agency (grant number 2023-11-25).
Declarations
Ethics Statement: Approval from the institutional review board of Soonchunhyang University Bucheon Hospital (SCHBC 2023-08-011-001) was obtained prior to the study.
Conflict of Interest: The authors have no conflicts of interest to declare.
Author Contributions: Conceptualization: YHH, SCC, HSJ. Data curation: SJP, YMN. Formal analysis: SJP, YMN. Investigation: YHH. SCC, HSJ. Resources: EGK. Supervision: SCC. Visualization: SJP, YMN. Writing – original draft: SJP, HSJ. Writing – review & editing: YHH, SCC.
REFERENCES
- 1.Kansra AR, Lakkunarajah S, Jay MS. Childhood and adolescent obesity: a review. Front Pediatr. 2021;8:581461. doi: 10.3389/fped.2020.581461.4ff9f56ecc554b3faf8aecff8964ce24 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hong YH. Pediatric obesity: life cycle approach of pediatrician and society. Clin Exp Pediatr. 2022;65:29–30. doi: 10.3345/cep.2021.01536.238c1f9554bc4b98a716e2b060c43c9d [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Park SY, Choo J. Ecological factors and strategies for childhood obesity prevention targeting vulnerable children: using community-based participatory research. J Korean Acad Community Health Nurs. 2020;31:256–68. doi: 10.12799/jkachn.2020.31.3.256. [DOI] [Google Scholar]
- 4.Choo J. An obesity prevention framework for vulnerable children based on a methodology of community-based participatory research: using a strategy of training community lay health advisors. Korea Health Promotion Institute; Seoul: 2013. Nov, [DOI] [Google Scholar]
- 5.Dietz WH, Belay B, Bradley D, et al. A model framework that integrates community and clinical systems for the prevention and management of obesity and other chronic diseases [Internet] National Academy of Medicine; 2017. [cited 2024 Jan 28]. Available from: https://doi.org/10.31478/201701b . [DOI] [Google Scholar]
- 6.Go DS, Choi MJ, Hong SW, Lee SH, Kim YE, Noh JW. Evaluation of healthcare organization based management program in Korea-using chronic care model. Korea J Hosp Manag. 2016;21:14–31. [Google Scholar]
- 7.Lasker RD, Weiss ES, Miller R. Partnership synergy: a practical framework for studying and strengthening the collaborative advantage. Milbank Q. 2001;79:179–205. III–IV. doi: 10.1111/1468-0009.00203. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ahn HK. Building collaborative governance between the central and local governments. The Korea Institute of Public Administration; Seoul: 2015. [Google Scholar]
- 9.McGlashan J, de la Haye K, Wang P, Allender S. Collaboration in complex systems: multilevel network analysis for community-based obesity prevention interventions. Sci Rep. 2019;9:12599. doi: 10.1038/s41598-019-47759-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
