Background: This study was performed to develop, evaluate, and implement an effective obesity intervention program using the DMAIC (Define, Measure, Analyze, Improve, Control) methodology.
Methods: A workplace obesity intervention program involving 100 obese male workers (% body fat ≥ 25% and BMI ≥ 25 kg/m2) was conducted five times (20~30 minutes each time) for 12 weeks. The intervention involved a face-to-face counseling.
Results: The selected critical to quality (CTQ) according to the Define phase was % body fat. The subjects’ mean % body fat, measured during Measure phase, was 27.8% and the sigma level was 0.54σ. According to the analyse phase, the total energy intake (r = 0.417; P < 0.001) and frequency
of exercise (r = -0.317; P < 0.01) were considered as potential factors influencing % body fat. Therefore, these factors were implemented in the intervention protocol. By performing six sigma methodologies, % body fat was significantly decreased from 27.8% to 26.2%, and the sigma
level was improved from 0.54σ to 1.27σ.
Conclusions: The six sigma methodology was well suited for implementing a more efficient and cost-effective intervention, for enhancing the quality of the intervention, and for facilitating the successful adoption of the process and protocol into practice.

Keywords: Obesity, Six sigma, Workplace, Intervention, Cost-effective

1. World Health Organization. The world Health Report:Reducing Risks, Promoting Healthy Life. Geneva :WHO; 2002.
2. Lawlor DA, Hart CL, Hole DJ, Smith GD. Reverse causality and confounding and the associations of overweight and obesity with mortality. Obesity 2006;14:2294-304.
   
3. Ouyang X, Lou Q, Gu L, Mo Y, Nan JH, Kong AP, et al. Cardiovascular disease risk factors are highly prevalent in the office-working population of Nanjing in China. Int J Cardiol Epub ahead of print 2010.
4. Tsai SP, Ahmed FS, Wendt JK, Bhojani F, Donnelly RP. The impact of obesity on illness absence and productivity in an industrial population of petrochemical workers. Ann Epidemiol 2008;18:8-14.
   
5. Neovius K, Johansson K, Kark M, Neovius M. Obesity status and sick leave: a systematic review. Obes Rev 2009;10:17-27.
   
6. Abdullah A, Peeters A, de Courten M, Stoelwinder J. The magnitude of association between overweight and obesity and the risk of diabetes: A meta-analysis of prospective cohort studies. Diabetes Res Clin Pract 2010;89:309-19.
   
7. Kushner RF, Sujak M. Prevention of weight gain in adult patients with type 2 diabetes treated with pioglitazone. Obesity 2009;17:1017-22.
   
8. Korea Centers for Disease Control and Prevention. 2009 National Health Statistics : Based on the Second 2009 Korea National Health and Nutrition Examination Survey; 2010.
9. Ahn BC, Joung HJ. Socioeconomic cost of obesity in Korea. Korean J Nutr 2005;38:786-92.
10. Jung YH, Ko SJ. Cost of illness due to smoking, alcohol, obesity and tax policies on the related products. The Korean Social Security Association 2009;2:275-309.
11. Ostbye T, Dement JM, Krause KM. Obesity and workers’ compensation: results from the Duke Health and Safety Surveillance System. Arch Intern Med 2007;167:766-73.
    
12. Sparling PB. Worksite health promotion: principles, resources, challenges. Prev Chronic Dis 2010;7:A25.
    
13. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health 2001;22:309-35.
    
14. Sagara T, Hitomi Y, Kambayashi Y, Hibino Y, Matsuzaki I, Sasahara S, et al. Common risk factors for changes in body weight and psychological well-being in Japanese male middle-aged workers. Environ Health Prev Med 2009;14:319-27.
    
15. French SA. Population Approaches to Promote Healthful Eating Behaviors. In Obesity Prevention and Public Health. In: D Crawford D and Jeffery RW, editor. 2nd ed. London: Oxford University Press;2010.
16. Proper KI, Hildebrandt VH. Overweight and obesity among Dutch workers: differences between occupational groups and sectors. Int Arch Occup Environ Health 2010;83:61-8.
    
17. French SA, Harnack LJ, Hannan PJ, Mitchell NR, Gerlach AF, Toomey TL. Worksite environment intervention to prevent obesity among metropolitan transit workers. Prev Med 2010;50:180-5.
    
18. Anderson LM, Quinn TA, Glanz K, Ramirez G, Kahwati LC, Johnson DB, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity : a systematic review. Am J Prev Med 2009;37:340-57.
    
19. Groeneveld IF, Proper KI, van der Beek AJ, van Mechelen W. Sustained body weight reduction by an individual-based lifestyle intervention for workers in the construction industry at risk for cardiovascular disease: Results of a randomized controlled trial. Prev Med 2010;51:240-6.
    
20. Barham K, West S, Trief P, Morrow C, Wade M, Weinstock RS. Diabetes prevention and control in the work place: a pilot project for county employees. J Public Health Manag Pract 2011;17:233-41.
    
21. Aldana SG. Financial impact of health promotion programs: A comprehensive review of the literature. Am J Health Promot 2001;15:296-320.
    
22. Cooper Z, Doll HA, Hawker DM, Byrne S, Bonner G, Eeley E, et al. Testing a new cognitive behavioural treatment for obesity: A randomized controlled trial with three-year follow-up. Behav Res Ther 2010;48:706-13.
    
23. Verweij LM, Proper KI, Weel AN, Hulshof CT, van Mechelen W. Design of the Balance@Work project:systematic development, evaluation and implementation of an occupational health guideline aimed at the prevention of weight gain among employees. BMC Public Health 2009;9:461.
    
24. Snee RD. Six sigma: the evolution of 100 years of business improvement methodology. Int J Six sigma Competitive Advantage 2004;1:4-20.
    
25. Kim YK, Song KE, Lee WK. Reducing patient waiting time for the outpatient phlebotomy service using six sigma. Korean J Lab Med 2009;29:171-7.
    
26. Dahl OJ. Cost and efficiency lead to increased value for the patient and bottom line for the practice. J Med Pract Manage 2009;25:87-9.
    
27. Kaplan S, Bisgaard S, Truesdell D, Zetterholm S. Design for six sigma in healthcare:developing an employee influenza vaccination process. J Healthc Qual 2009;31:36-43.
    
28. DuPree E, Martin L, Anderson R, Kathuria N, Reich D, Porter C, et al. Improving patient satisfaction with pain management using six sigma tools. Jt Comm J Qual Patient Saf 2009;35:343-50.
    
29. Fischman D. Applying lean six sigma methodologies to improve efficiency, timeliness of care, quality of care in an internal medicine residency clinic. Qual Manag Health Care 2010;19:201-10.
    
30. DelliFraine JL, Langabeer II JR, Nembhard IM. Assessing the evidence of six sigma and lean in the health care industry. Qual Manage Health Care 2010;19:211-25.
    
31. Garcia-Porres J, Ortiz-Posadas MR, Pimentel-Aguilar AB. Lean six sigma applied to a process innovation in a Mexican Health Institute’s imaging department. Conf Proc IEEE Eng Med Biol Soc 2008;2008:5125-8.
    
32. World Health Organization. The Asia-Pacific Perspective: Redefining obesity and its treatment. Geneva : World Health Organization Western Pacific Regional Office; 2000.
33. Ahn YJ, Lee JE, Paik HY, Lee HK, Jo IH, Kim KC. Development of a semi-quantitative food frequency questionnaire based on dietary data from the Korea National Health and Nutrition Examination Survey. Nutr Sci 2003;6:173-84.
34. Kosaka K, Noda M, Kuzuya T. Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diabetes Res Clin Pract 2005;67:152-62.
    
35. Morgan PJ, Collins CE, Plotnikoff RC, McElduff P, Burrows T, Warren JM, et al. The SHED-IT community trial study protocol: a randomised controlled trial of weight loss programs for overweight and obese men. BMC Public Health 2010;10:701.
    
36. Ahn HJ, Cho YO, Kwon HR, Ku YH, Koo BK, Han KA, et al. The effects of low-calorie diets on abdominal visceral fat, muscle mass, dietary quality in obese type 2 diabetic subjects. Korean Diabetes J 2009;33:526-36.
    
37. American Diabetes Association, Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008;31 Suppl 1:S61-78.
    
38. Lee JS, Kawakubo K, Kobayashi Y, Mori K, Kasihara H, Tamura M. Effects of ten year body weight variability on cardiovascular risk factors in Japanese middle-aged men and women. Int J Obes Relat Metab Disord 2001;25:1063-7.
    
39. Snijder MB, van Dam RM, Visser M, Seidell JC. What aspects of body fat are particularly hazardous and how do we measure them? Int J Epidemiol 2006;35:83-92.
    
40. Meeuwsen S. Horgan GW, Elia M. The relationship between BMI and percent body fat, measured by bioelectrical impedance, in a large adult sample is curvilinear and influenced by age and sex. Clin Nutr 2010;29:560-6.
    
41. Calling S, Hedblad B, Engstr?m G, Berglund G, Janzon L. Effects of body fatness and physical activity on cardiovascular risk: risk prediction using the bioelectrical impedance method. Scand J Public Health 2006;34:568-75.
    
42. Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:517-84.
    
43. Gastaldelli A, Miyazaki Y, Pettiti M, Matsuda M, Mahankali S, Santini E, et al. Metabolic effects of visceral fat accumulation in type 2 diabetes. J Clin Endocrinol Metab 2002;87:5098-103.
    
44. Yan SJ, Li YM, Shen XM, Yang LY, Zhang SJ, Yi RH, et al. Use body fat determination instead of simple body composition parameters evaluate the risk of metabolic syndrome in Fuzhou adults. Zhonghua Yi Xue Za Zhi 2010;90:1678-81.
    
45. Peltz G, Aguirre MT, Sanderson M, Fadden MK. The role of fat mass index in determining obesity. Am J Hum Biol 2010;22:639-47.
    
46. Yoo HJ, Kim BT, Park YW, Park KH, Kim CW, Joo NS. Difference of body compositional changes according to the presence of weight cycling in a community-based weight control program. J Korean Med Sci 2010;25:49-53.
    
47. Kwon HR, Min KW, Ahn HJ, Seok HG, Koo BK, Kim HC, et al. Effects of aerobic exercise on abdominal fat, thigh muscle mass and muscle strength in type 2 diabetic subject. Korean Diabetes J 2010;34:23-31.
    
48. Park HD, Kim EJ, Hwang MO, Paek YM, Choi TI, Park YK. Effects of workplace nutrition education program tailored for the individual chronic disease risks. Korean J Nutr 2010;43:246-59.