Further discussion of community- and population-level strategies

Wharton and colleagues provide an excellent overview of the complexity of obesity and multiple biological, behavioural and environmental contributors.¹ While the resulting clinical practice guideline (CPG) provides a launching pad to abandon the flawed notion of obesity as a self-inflicted condition and redefine the clinical approach to treating and managing obesity in Canada, the critical roles of retail food environments and the affordability of healthy food were regrettably overlooked. Although it is appreciated that the CPG was intended to provide guidance for individual-level strategies, individual efforts without parallel efforts at a community or population level may limit overall success in improving obesity-related outcomes among patients.

Increasing evidence suggests that retail food environments play a role in body mass index (BMI);² however, inconsistent findings are likely due to variability in food environment measurements and lack of consideration of interindividual differences in food cue reactivity. Recent research supports an argument for interindividual differences in responsivity to food cues in the retail food environment, including advertising exposures such as in-store food displays.³ While additional research in this area is anticipated, the role of socioeconomic status in obesity is more conclusive.

Low socioeconomic status is consistently associated with obesity. An investigation of gene-obesogenic environment interactions in the UK Biobank concluded that low socioeconomic position accentuated genetic susceptibility to obesity and captured the relevant environmental factors. ⁴ Affordability of healthy food is a recognized barrier to healthy eating and may be a particularly relevant target for obesity intervention. Given this relationship, efforts like Geisinger’s Fresh Food Farmacy, which provides healthy food to people living with diabetes and facing food insecurity, are needed to show the possible benefit of community intervention addressing food affordability. Participants in the Fresh Food Farmacy initiative are prescribed fresh food each week and fill the prescription (i.e., pick-up food) at the Farmacy clinic, alleviating financial barriers and retail exposures that pose challenges to healthy eating. Preliminary results from the initiative include a staggering 2-point reduction in hemoglobin A_1c levels among participants along with reductions in low-density lipoproteins, triglycerides, blood pressure and BMI.⁵

Wharton and colleagues have illuminated the urgent need for access to appropriate and holistic obesity care in Canada. However, strategies for improving community- and population-level factors need attention, investigation and action to disrupt conventional approaches to treating and managing obesity.