Pediatric obesity is a chronic disease shaped by biological, behavioral, familial, social, and environmental factors, and its prevention and management extend beyond clinical settings. Schools, families, public health services, community organizations, primary care providers, and specialists each have a role. Yet the involvement of many sectors does not, by itself, create an integrated system.
When responsibilities are poorly defined and the connections between sectors are weak, children and their families may encounter several programs without a clear pathway to continuing care.
In this issue of the Journal of Obesity & Metabolic Syndrome, Park et al.1 report a qualitative study of 25 providers from 18 institutions delivering pediatric obesity prevention and management programs in schools and local public health centers in Korea. Providers in both sectors agreed that schools should lead programs with support from public health centers, but they described limited resources, difficulty engaging families, weak coordination within and across institutions, inconsistent referral pathways, and a gap in services for children and adolescents who do not attend school. The scale of the problem makes such fragmentation particularly concerning: in the 2025 student health examination sample statistics, 29.7% of Korean students were overweight or obese, and the proportion was higher in rural areas than in cities (33.2% vs.
29.0%).2 The findings echo earlier nationwide survey data showing a substantial gap between the perceived importance of institutional coordination and its implementation.3 Together, these studies suggest that the problem is not simply a shortage of programs but a lack of continuity between them.
Identification is not care
A central question raised by the study is what happens after a child is identified as needing additional support. Neither education nor public health providers consistently facilitated access to medical care.1 School providers tended to regard subsequent treatment as the responsibility of parents or guardians, whereas public health providers cited limited specialized knowledge and uncertainty about where to send children. Identifying a child at risk, however, is not the same as ensuring that the child receives care.
A result notice sent home, or a recommendation to consult a physician, should not be counted as successful linkage. Loss to follow-up after referral can be substantial: in a large pediatric weight management program in the United States, only 41.2% of 4,783 referred children attended a first visit.4 Referral is a starting point, not an outcome.
A similar gap is evident in clinical care. In a recent survey of 200 Korean physicians involved in pediatric obesity management, fewer than half (46.0%) reported an institutional protocol, nearly three-quarters spent 20 minutes or less per consultation, and limited reimbursement constrained active intervention. Yet, when asked which institution mattered most for management, physicians most often named schools.5 School providers in the qualitative study saw treatment as the family’s responsibility, and physicians in the survey identified schools as their most important partner.
Together, the two findings illustrate a disconnect between community programs and clinical services, rather than a lack of commitment from either sector. Integrated care frameworks accordingly emphasize team-based care, care coordination, self-management support, and reliable links between health care and community resources.6
School-centered should not mean school-burdened
Schools are essential settings for pediatric obesity prevention because they offer broad, repeated access to children and can contribute to health promotion, early identification, and engagement. Providers interviewed by Park et al.1 agreed that schools should lead. However, school-centered care should not overburden schools.
Schools are educational institutions, not obesity clinics. Teachers and school health staff already carry heavy workloads, and expecting them to identify obesity, deliver intensive interventions, arrange clinical referrals, and ensure long-term follow-up without support would shift responsibility without resolving fragmentation.
The same principle applies to other sectors. Local public health centers are well positioned to support population-level prevention, community programs, and coordination, but they cannot substitute for longitudinal clinical care. Primary care providers can assess obesity severity and comorbidities, initiate treatment, and follow children over time, while specialist services are needed for severe or complex obesity.
Community resources can support nutrition, physical activity, behavior change, and family engagement. Sustainability is a shared challenge: unstable funding, inconsistent participation, and insufficient staff repeatedly threaten community programs, making partnerships essential for sustainability.7 The implication is clear: no single sector has the capacity, or should be expected, to address pediatric obesity alone. The priority is therefore not to designate a single central institution but to connect the services surrounding each child.
From referral to a child-centered pathway
Integration requires more than transferring responsibility between sectors; it requires defining what each sector is best positioned to provide and building reliable connections between them. A child-centered system should allow several points of entry, including school health examinations, public health or community programs, and routine health care, all leading to a common sequence:
Identification → Engagement → Assessment → Intervention matched to need, with referral when indicated → Longitudinal follow-up.
Not every child with overweight or obesity requires specialist care. Assessment should guide each child toward care appropriate to obesity severity, comorbidities, and family circumstances, consistent with current guidelines,8,9 so that community support, primary care, and specialist services operate as a coordinated continuum, with referral between them when indicated rather than as a final step. Each handoff needs a clearly designated person responsible.
A designated coordinator who confirms that a family has been contacted, that the first visit has occurred, and that children lost to follow-up are contacted again is the difference between a referral route and a working pathway.6
The proposed pathway also highlights an equity concern. Neither sector in the study reported programs that consistently reach children and adolescents who do not attend school.1 A system that relies predominantly on schools may therefore fail to reach some particularly vulnerable children, which is why entry through community and health care settings must remain open.
The next challenge is implementation
The framework proposed by Park et al.1 should be viewed as a starting point rather than a fully developed organizational model. As a qualitative study of provider perspectives, it identifies practical barriers and candidate solutions, but it does not establish which delivery model improves clinical outcomes or specify operational protocols. Several practical questions remain.
Who coordinates care? How does information move between schools, public health services, and health care while protecting privacy? How are referral completion and loss to follow-up monitored?
How can families be engaged without reinforcing weight stigma, a concern that Korean caregivers themselves raise?10 How can coordination be funded sustainably?
These questions are increasingly pressing as treatment becomes more intensive. Current guidelines call for comprehensive, longitudinal management, including structured health behavior and lifestyle treatment and, where appropriate, pharmacotherapy or metabolic and bariatric surgery,8,9 and the United States Preventive Services Task Force recommends that clinicians provide or refer children aged 6 years or older with a body mass index at or above the 95th percentile to intensive behavioral interventions of 26 or more contact hours.11 As effective care becomes more intensive, identifying children without establishing access to such care becomes increasingly difficult to justify.
Recent policy developments in Korea could help address these gaps. Under the amended School Health Act, student health examinations are being delegated to the National Health Insurance Service from March 2027, and the Fourth National Health Screening Master Plan (2026–2030) expands blood testing to students with overweight and introduces prevention and management services for children with overweight or obesity in which families, schools, and communities participate together.12,13 These changes offer an opportunity to connect student health screening with subsequent assessment and care. Whether this opportunity leads to completed referrals and sustained treatment will depend on implementation.
We are currently conducting a Korea National Institute of Health-supported implementation study testing such a pathway in two pilot regions: a designated coordinator links school examination results to primary care and community resources, and success will be judged by referral completion and retention rather than by enrollment alone.
Measures of success should reflect these priorities. Rather than counting children screened, participants enrolled, or programs delivered, evaluations should determine whether children who need support receive appropriate intervention, reach health care when needed, and stay engaged over time. The priority is to connect existing programs rather than simply create new ones, with the child rather than any single institution at the center.
Referral pathways from schools or public health centers to clinics alone will not ensure continuity. Both sides of the pathway must be ready: community settings need reliable routes for referral, and the health care system needs the capacity to receive, assess, treat, and follow children over time.