Background and Context

Obesity is a state of imbalance in the caloric expenditure where the caloric uptake exceeds
calories consumed for energy. Several factors contribute to developing obesity, some are
inherent such as genetics, and medical conditions that impair metabolism, while others are
lifestyle factors such as imbalanced diet and physical inactivity. Obesity is a risk factor for
several none communicable diseases (NCDs) such as type II diabetes, heart diseases, strokes,
and cancers. The overall effect of obesity on the quality of life is similar to the effects of
poverty, smoking and alcohol misuse.
According to the Organization of Economic Co-operation and Development, among the
countries with the highest obesity prevalence, Canada ranks fifth. In 2017, 64% of Canadian
adults were overweight or obese. Obesity costs the Canadian economy between $4.6 and $7.1
billion annually. In Canada, the federal and provincial governments make public health (PH)
decisions. Local PH policies are made at the province level and implemented in all cities within
the province. The setting of this essay is in Atlantic Canada, a province with a population of
2.5 million.
Aim
In this essay, I will advise the local government on the development and implementation of
health improvement interventions that aim to tackle obesity in Atlantic Canada. I will do this
by comparing different interventions implemented at the population-level and individual level
in terms of health benefits, cost-effectiveness, implementation feasibility, and inequalities.

Public Health Approaches

The fundamental goal of PH is to promote the population’s health. To achieve this goal two
main approaches are used: the population level and the high-risk approach. The aim of the
population-level strategies is to target the risk factors for the whole population regardless of
the individual susceptibility. This aim is achieved by lowering the risk of developing obesity
by a small amount for the whole population equally. One important concept that helped to
shape the current understanding of the population level strategy is the prevention paradox by
Rose. He illustrated how the majority of the cases come from low and moderate risk groups in
the population rather than the high-risk group. In the population level strategies, the
interventions are designed to shift the whole population distribution toward a favorable
direction. An example of the population-wide strategy is the legislative and fiscal policies such
as sugar-sweetened beverages (SSBs) taxation in Mexico. In the second approach, the high-
risk (individual), the aim is to identify the high-risk group and then to tailor a strategy to lower
their risk of developing obesity by a significant amount. An example of the high-risk approach
is the combined physical activity (PA) and diet programs for overweight and obese individuals.

The Population Level Approach Versus High-risk Approach

In order to be able to advise for an effective PH strategy, one vital step, is to understand why
Canada has this obesity prevalence? For that, I will focus on the two main modifiable aspects Commented [SKDS1]: Rephrase this as questions aren’t
really appreciated in academic writing
of obesity, diet, and PA. Findings from the Canadian Health Survey showed that there is a
significant increase in the consumption of highly processed energy-dense food, and
deficiency in meeting the minimum required daily servings of healthy food (e.g., fruits and
vegetables). The vast majority of the products consumed by the population are high in sugar,
salt, refined carbohydrates, and fat. The Canadian population, as well, do not meet the
activity guidelines of the Canadian Society for Exercise Physiology and children active play
is reducing significantly in new Canadian communities. The question to raise here is why the
Canadian population have those food consumption patterns? Commented [SKDS2]: Probably use evidence instead of
open ended questions
Moreover, why they are not meeting the required PA levels? A multitude of factors (i.e., at the
international and national level) contribute to the development of the current obesogenic Commented [SKDS3]: Expand on what this means, there is
plenty of papers explaining why obesogenic environments
environment in Canada. For example, the junk food industry, the global supply of food, the appear and how this is relevant to population preventive
strategies
limited access to healthy food options, the high cost of exercise facilities, the current urban
Connecting from above, where you asked questions, instead
design, and the technological advances. In population-wide approaches, we develop strategies use evidence saying that the obesogenic environments are
caused by social, environmental factors.
to improve the population health by targeting the environmental factors (i.e., the cause of the
Commented [SKDS4]: This is your key point --- that
cause). However, in the high-risk strategies, following the preventive medical model, high- environments cause obesogenic environments so I would
expand on this
risk individuals are identified through screening or upon medical referral. Those individuals
are enrolled in designed programs, that change their behavior toward following a healthier
lifestyle (i.e., a balanced healthy diet and optimal PA levels).

Health Benefits
The current literature shows that both approaches have a statistically significant positive
effect in terms of health benefits. One example for the population approach is the physical
activity across the curriculum (PAAC) randomized control trial (RCT) by Donnelly et al. the
objective of this trial was to promote PA and reduce obesity in elementary school children.
Twenty-four schools were cluster randomized to the PAAC, over three years, they have
promoted 90 minutes per week moderate to high-intensity PA. BMI measurement was the
primary outcome in this trial. The result of this trial showed that 75 minutes, or more, per
week of PAAC, was significantly associated with less increase in BMI (1.8) compared to
schools with less than 75 minutes per week (2.4) with a p-value of 0.02.
Another population-wide strategy, implemented at a higher level, is the SSB taxation in
Mexico. The Mexican government introduced this fiscal policy in 2014, with a 10% price
increase for SSBs. One-year follow-up showed a 12% reduction in the sales of SSB and an
increase in water and milk consumption. Colchero et al. found that price elasticity was higher
for both marginalized and lower-income households, were they found to be more sensitive to
the price change compared to other population groups. However, although, the current results
are shown to be promising, this policy is relatively recent. Robust evaluation is needed to
investigate if the sales reduction is attributed to the policy and if it had a desirable effect on
obesity epidemics.
At the individual level, a Cochrane review was done to summarise the evidence of PA and diet Commented [SKDS5]: Should this be high-risk approach?

RCTs interventions. The review included 43 studies and a total of 3476 obese or overweight
participants. The result of the review found that combined PA and diet programs resulted in
higher weight loss compared to diet interventions alone (-1.0 kg with a 95% confidence interval
of -1.3 to -0.7). Also, they found that increasing the intensity of the PA, increased the
magnitude of the weight loss (-1.5 kg with a 95% confidence interval of -2.3 to -0.7). Overall,
in terms of weight reduction, both approaches were found to be effective, or indicate potential
effectiveness (e.g., SSB taxation).

Cost-effectiveness
The cost of the intervention is a core component of its application and fundamental to its
sustainability. In the current literature, several arguments are present, regarding the cost-
effectiveness of both approaches. One argument in favor of the high-risk approach, find it to
be cost-effective as it allocates the resources to maximize health benefits. The proponents of
the population-wide interventions find it be cost-effective as it results in making radical
environmental changes.
An economic evaluation (i.e., cost-effectiveness analysis) of a school-based - population
strategy - obesity prevention program, in the United States of America (US), is found to be
cost effective. The intervention cost $14 per student per year and prevented 1.9% of female
students from developing obesity. This program is found to save 4.1 quality-adjust life-year
(QALY). The society would save $15,887 of medical care costs and $25104 of lost
productivity costs. In this intervention, $4305 is the cost per QALY saved which is cost-
effective at the $50,000 US cost-effectiveness threshold. Another cost-effective - at the US
threshold - population-based intervention is Wheeling Walks at Wheeling, West Virginia,
US. In this intervention, the cost of one QALY gained was $14,286.
For the high-risk approach, several interventions were found to be cost-effective. Orlistat, for
example, is one of the pharmaceutical interventions for obesity. Orlistat is cost-effective, with
a cost ranging from $8,327 to $37,795 per QALY gained. Bariatric surgeries are another cost-
effective high-risk intervention. The cost of QALY saved by bariatric surgeries ranges from
$5,000 to $35,000, according to the initial BMI before the surgery. In sum, in terms of the cost-
effectiveness, both approaches were found to be opposed and (or) supported in the literature. Commented [SKDS6]: Don’t get the point. Opposed?

Implementation Feasibility
One important concept to discuss regarding obesity interventions is the level of “Agency” in
the interventions. Agency in this context refers to the personal autonomy and responsibility to
utilize personal resources in order to benefit from the intervention. Interventions with a high
level of agency - high level of autonomy and personal responsibility – (e.g., social marketing
and mass media campaigns) are far more preferable by both policymakers and the public.
Interventions with a low level of agency (e.g., fiscal policies) are found to be the most effective
and equitable. Despite their proven effectiveness, several obstacles prevent the implementation
of low agency interventions. First, politicians are usually reluctant to make such high impact
decisions where they are driven by their political interests, the need for high-level evidence,
their time constraints and election priorities. Second, low agency interventions are mostly
opposed by the industries, and manufacturers use substantial resources to refute the evidence
supporting those interventions. Third, public response and acceptability of low agency
interventions are profoundly affected by the impact of the intervention on their autonomy.
Inequalities
Reducing health and socioeconomic inequalities is always one of the objectives of any PH
intervention. The current evidence is inconclusive in terms of the inequalities associated with
two approaches. Thomson et al. conducted a systematic review to investigate the effect of PH
interventions on health inequalities in high-income countries. The results of this review were
mixed, and both approaches were found to reduce and (or) have no effect on inequalities. For
example, some population-wide interventions were found to reduce inequalities (e.g., food
subsidy programs), while others did not affect such as the national salt reduction strategy.
Within the Canadian context, it is proven that low-income groups usually have restricted food
options where they found the least healthy food to be the most affordable.
Recommendations
In ideal circumstances both approaches, population-wide and high-risk, are complementary
and there will always be a trade-off by focusing on only one of them. Considering the above-
mentioned Canadian context, in this essay, I will advise for local government to adopt the
population-wide approach as their key strategy for tackling obesity. The core reasons for
Canada to develop the current obesity epidemics are attributed to a multitude of complex
environmental driven factors. The approach should focus the local efforts to build equitable,
sustainable, and healthy public policy and supportive environment. The approaches should
bring sustainable change by adopting concepts of social cognitive theory (SCT). The SCT is
proven to provide a dynamic, reciprocal framework where the personal, environmental and
behavioral factors are all considered. One of the primary theoretical constructs in the SCT is
self-efficacy, and it is mainly found to be associated with successful health behavior change in
obesity.
Conclusion
In this essay, I have provided an argument for the adoption of the population level approach to
tackle obesity in the Province of Atlantic Canada, Canada. Obesity is a huge PH concern as it
is a significant risk factor of many NCDs, and obesity prevalence in Canada is reaching an
alarming rate. The population-wide approach targets upstream factors and promotes healthier
environments. While the high-risk strategy provides practical, evidence-based programs to
reduce weight, comparing PH approaches - in terms of health benefits, cost-effectiveness,
implementation feasibility, and inequalities - both were found to be supported and opposed in
the literature. Trade-offs always exist when selecting one of them. However, considering the
complex, multifactorial nature of obesity, population-wide interventions should be an effective
key strategy in Atlantic Canada.