Dear Editor:

We read with great interest “Controlling the obesity pandemic: Geoffrey Rose revisited” (Frank, 2022). It is an important reminder of the value and potential of applying a population strategy for obesity control. Beyond revisiting Rose, we offer additional suggestions for reimagining “control of the causes of incidence” for obesity (Rose, 2001).

Shift further upstream

Knowledge regarding the prevention and treatment of obesity has advanced beyond an “eat less, move more” approach (Wharton et al., 2020); however, translation of this knowledge into clinical care and public health is slow. Frank highlights that population-level interventions can effectively and equitably reduce dietary-related disease risk (e.g., food reformulation). We propose the need to shift even further upstream than food for primordial prevention (Link & Phelan, 1995), focussing on other impactful targets to address poverty, and equitable access to healthy environments. Primordial interventions that address the fundamental determinants of health are likely to positively impact many health outcomes and their impacts may persist if intervening mechanisms change.

Learn from other pandemics

Preliminary evidence suggests that the prevalence of obesity may have increased during the COVID-19 pandemic (Daniels et al., 2022). If factors associated with public health restrictions (e.g., increased stress, poor mental health, income precarity, and reduced access to schools, community centres and safe spaces for children, and community and healthcare resources) resulted in an increase in obesity, then perhaps those are the same population-level targets that need to be addressed to reduce obesity. The COVID-19 pandemic has demonstrated that sweeping changes at the population level are possible.

Consider a life cycle approach

An intergenerational approach to obesity prevention should be considered. Obesity transmission in families and social networks is high (Christakis & Fowler, 2007; Pollard et al., 2011). Parents with obesity are more likely to have children with obesity for a variety of reasons, including community factors, socioeconomic position, shared behaviours, and genetics. While secondary or tertiary prevention that targets adults with obesity now may be designed as a high-risk approach, it could also be thought of as primordial prevention, shifting the curve for the next generation.

Tackle obesity stigma and weight bias

Obesity is a serious disease; however, misconceptions about the causes and consequences create additional barriers to disease control (Puhl & Heuer, 2010). An enhanced recognition of social and structural factors as obesity causes may reduce weight bias, a barrier that is frequently experienced by people with obesity. Weight stigma may also limit investment in obesity prevention (Puhl & Heuer, 2010). Reducing weight stigma could possibly be a valuable target for obesity prevention strategies.

In conclusion, while challenges to upstream interventions exist, there is room for optimism and action now. In the decades prior to the COVID-19 pandemic, the prevalence of childhood obesity in North America had plateaued and decreased in some age groups (Ogden et al., 2016; Rodd & Sharma, 2016). There are currently several “radical” population changes occurring in Canada that may be seen as primordial prevention, most notably investments in Early Learning and Child Care, and the Canada Child Benefit. While the impact of these policies on health outcomes such as obesity is not yet known, they may have the potential to reduce child obesity through upstream prevention. We agree with Frank that primordial prevention for obesity is necessary and suggest that now may be the time to reimagine primordial prevention.