Journal of Public Health | Vol. 34, No. 4, pp. 548 – 554 | doi:10.1093/pubmed/fds036 | Advance Access Publication 18 May 2012
‘McDonalds and KFC, it’s never going to happen’: the
challenges of working with food outlets to tackle
the obesogenic environment
Barbara Hanratty1,2, Beth Milton1, Matthew Ashton1, Margaret Whitehead1
1
Department of Public Health and Policy, University of Liverpool, UK
Department of Health Sciences/Hull York Medical School, Alcuin C/008, University of York, Heslington, York YO10 5DD, UK
Address correspondence to Barbara Hanratty, Email: [email protected]
2
A B S T R AC T
Background Food outlets may make an important contribution to an obesogenic environment. This study investigated barriers and facilitators
to public health work with food outlets in disadvantaged areas.
Methods In-depth qualitative interviews with 36 directors, managers and public health service delivery staff in a coterminous primary care
trust and local authority in northwest England. Data were analysed using the constant comparative method.
Results Three interventions were available to engage with businesses; awards for premises that welcomed breastfeeding mothers or offered
healthy menu options and local authority planning powers. Sensitivity to the potential conflict between activities that generate profit and
those that promote health, led to compromises, such as awards for cafés that offer only one healthy option on an otherwise unhealthy menu.
An absence of existing relationships with businesses and limited time were powerful disincentives to action, leading to greater engagement
with public rather than private sector organizations. Hiring staff with commercial experience and incentives for businesses were identified as
useful strategies, but seldom used.
Conclusions Encouraging food outlets to contribute to tackling the obesogenic environment is a major challenge for local public health
teams that requires supportive national policies. Commitment to engage with the local public health service should be part of any national
voluntary agreements with industry.
Keywords (MeSH headings) socioeconomic factors, public health practice, prevention and control, obesity
Introduction
Obesity is rising across the world. In England, data from
the National Child Measurement Programme show that one
in three children are overweight or obese at ages 10 and 11,1
whilst one in four adults are obese.2 Diet and exercise are
the main aetiological factors in the development of obesity,3
and there are many important influences on these that are
beyond the control of the individual, from the globalization
of the food industry to national transport policies and local
environmental planning and management. To prevent or
reduce levels of obesity, interventions aimed at individuals—
dietary advice, for example—will not be successful on their
own. Supporting action on the environment is also required
at a population level.
Disadvantaged areas are often ‘obesogenic environments’;
a term used to describe the role that environmental factors
play in promoting a poor diet and obesity.4 – 6 Physical activity levels are low amongst children who live in obesogenic
environments,7,8 and disadvantaged areas are less likely to
provide safe, green spaces in which to exercise. Although
Barbara Hanratty, NIHR Career Development Fellow
Beth Milton, Research Fellow
Matthew Ashton, Honorary Research Fellow
Margaret Whitehead, WH Duncan Professor of Public Health
548
# The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved
CH A L L E NG E S O F WO RK I N G W I T H FO O D O U T L E T S
the association between the area level disadvantage and
obesity is most clear cut in the USA, where neighbourhoods
are relatively homogeneous with respect to socioeconomic
characteristics, a similar picture is apparent in the UK.
Poorer areas are more likely to offer unhealthy food
options,9 – 11 and have a higher density of fast food outlets.
Proximity to fast food retailers has been associated with
higher weight and less healthy eating habits.12 In the UK
and Ireland, the density of fast food outlets was found to
correlate closely with levels of obesity amongst children.13,14
Breastfeeding is also lower amongst disadvantaged women,
and it has been implicated in the subsequent development
of overweight and obesity.15,16
A review of the evidence for local authorities in England,
on how to reduce levels of obesity, recommended giving
thought to the availability and access to healthier food
choices.17 Food sold in cafes, restaurants and takeaways is
an important contributor to diet and a potential influence
on levels of obesity and overweight in an area. The use of
existing planning powers to control the number of fast food
outlets near schools has been promoted in government
strategy on healthy weight.18 In addition, the Local
Government Act 2000 allows local authorities in England
and Wales to do anything they believe will promote the economic, social and environmental well-being of their area,
unless prohibited elsewhere in law.19 These ‘Well-Being
Powers’ have been interpreted as a potential mechanism for
improving the health of local residents, though they have
not been widely used.20 Such regulatory approaches frame
the problem of obesity as a response to an obesogenic environment. The food industry, and more recent UK government thinking, consider individual responsibility to be
important.21 At a local level, public health practitioners are
attempting to bridge this divide, and work with retailers, to
encourage them to offer healthy food choices to their customers. In disadvantaged areas, where food retailers provide
cheap options to people on low incomes, this is a particular
challenge.
In this paper, we explore the experiences of public health
workers in a Primary Care Trust and their local authority
colleagues. The aim is to identify the barriers and facilitators
to working with commercial food providers to promote
healthy eating in a disadvantaged area.
Methods
The study was set in a Spearhead PCT and co-terminous
local authority in north-west England. Thirty-six semistructured in-depth interviews were conducted with senior
and middle managers, frontline staff and those who were
involved with reduction of obesity, healthy weight promotion
and reduction in cardiovascular disease rates. Data collection
focused on exploring participants’ experiences of working
549
with commercial food outlets (cafes, restaurants and
takeaways) to tackle the ‘obesogenic environment’ in disadvantaged areas. The participants all played a part in the local
approach to tackling the obesogenic environment, which
included working with food outlets. As their roles ranged
from setting and implementing strategy to service delivery,
we anticipated collecting data relating to a range of experiences in health promotion.
A sampling frame was designed in collaboration with a
senior manager at the PCT, using theoretical sampling principles, and expanded purposively as the study went on.
Fourteen senior managers took part in the study. From the
PCT these were the Director and two Assistant Directors of
Public Health, the Chairperson and the Director of Health
and Social Care. From the LA: the Directors of
Environmental Health, Leisure and Cultural Services,
Children’s Services, Crime and Disorder and Regeneration,
together with two elected Councillors. Two senior managers
were also recruited from the voluntary, community and faith
sector. Fourteen middle managers participated. Six of these
were from the LA (and worked in Travel Planning, Leisure
Centre Management, Planning and Green Spaces), six were
from the PCT ( public health programme leads). Two were
from other sectors (working at Children’s Centres and a
food charity). Nine front-line members of staff also took
part: one from the PCT (working on infant feeding), seven
from the LA (involved in playwork, as a ranger, in environmental health, travel planning and planning) and one from
another sector (a charitable food project). To preserve the
anonymity of the participants, detailed descriptions of their
roles are not attached to direct quotations. Research Ethics
Committees in the NHS and University judged the study to
be a service evaluation, not requiring approval (Personal
communication, NHS REC North West, August 2009).
Written information about the study was sent to each participant in advance, and informed consent obtained immediately prior to the interview. All of the interviews took place
in the participants’ workplaces and lasted for no longer than
an hour. Digital recordings were transcribed verbatim; field
notes and observations were recorded and contributed to
the interpretation of findings.
Data analysis was carried out alongside the interviews,
and the findings informed subsequent data collection. Data
were analysed using the constant comparative method, and
the analysis was implemented using NVivo software (version
8). After the data were open coded (examined in detail and
categorized using inductive coding), axial coding was used
to reassemble the data into appropriate connected categories. Finally, selective coding was used to formulate a coherent account of the whole data set. Themes were discussed
and refined with the research team as they emerged from
the data. The themes described are based on data generated
by all participants, but the quotes were taken from staff
550
J O U RN A L O F P U B L I C H E A LTH
most closely involved. They were chosen to represent the
themes in a succinct manner. As there were two interventions being actively promoted, there were inevitably a small
number of staff directly involved in each area of work.
Findings
As part of the Healthy Weight strategy within the study area,
the local authority and the Primary Care Trust aimed to
engage with the commercial food sector with three specific
initiatives: a Breastfeeding Welcome Award (for premises
who welcome breastfeeding mothers), an Eat Well Award
(for food outlets with good standards of food hygiene which
also offer healthy options) and the use of the local authority
planning regulations (Wellbeing Powers) to restrict the
number of hot food takeaway outlets within the borough.
Three main themes emerged from the data analysis: the conflict between health and profit-making, public sector relationships with business and real world compromises.
Conflict between health and profitmaking
Staff were concerned that health was a low priority for businesses in comparison with the need to generate profits.
They acknowledged the potential incompatibility between
promoting health and maximizing profit, and the possibility
that the changes to working practices that they were advocating could have negative consequences for the profits of
local businesses:
It is important to understand the fact that this is a
business first. And even if you are a social enterprise,
you still need to have your head above water. And
sometimes other people can forget that. And I think
you have to be careful in that you can’t be making
really big changes with organisations that might make
them vulnerable because it will just turn them off, in
terms of engaging with you (Manager, Public Health,
PCT).
There were high levels of socioeconomic disadvantage
within the study area, and many hot food takeaways serving
the local residents. Although the Eat Well Award sought to
encourage food outlets to offer healthy choices, staff
reported that they did not expect to engage some burger
bars, because they felt that they had little leverage with restaurants that were part of a chain or large commercial
group:
The likes of McDonalds and KFC, it’s never going to
happen, but they did get the Food Hygiene because
they are clean (Senior staff member, Environmental
Health, Local Authority).
Breastfeeding initiation rates in the borough were very low,
and staff were aware that breastfeeding was not regarded as
normal, acceptable behaviour by many local people—indeed
they reported that it sometimes generated strong negative
reactions. There was also a perception held by NHS staff
that some businesses did not wish to participate in the
Breastfeeding Welcome Award scheme for fear of alienating
their other customers:
Participant: . . . Some of them are quite positive and say
‘Oh yes we welcome breastfeeding mums here, but we
don’t want to put a sticker up in our window. And they
are welcome but we don’t want to join your scheme.’
Interviewer: Are they stating why they don’t want the
sticker in the window?
Participant: My impression would be that they don’t
for their other customers (Public Health staff member,
PCT).
Public sector relationships with businesses
The NHS staff did not have established relationships with
the commercial sector, and were concerned that it would
not be easy to engage with businesses. They perceived the
local authority staff to have had more experience in working
with businesses.
Senior staff acknowledged that certain skills are required
to build a good relationship with businesses. People who
had worked outside of the public sector and were able to
understand businesses’ concerns and propose real-world
solutions were seen as an asset:
Participant: We were really lucky when we appointed
the person that used to do that job [implementing the
Eat Well award] because he was a chef in a former life,
who wanted to become an enforcement officer and
whilst being a chef . . . it was great because they
couldn’t bullshit him because he knew. He was like ‘Oh
don’t talk rubbish’. If they were ‘Oh it’s too expensive
to do that, oh you can’t get them from the suppliers’.
He would say ‘Oh if you go to the wholesaler you can
get that on Aisle 3B’. So we were really lucky I think
and once we reappoint to that post I think we will be
looking for more of a sales-directed person . . . (Senior
staff member, Environmental Health, Local Authority).
While the original intention was to use the Breastfeeding
Welcome Award widely across the local authority area to
denote that mothers were welcome to breastfeed in premises
of all kinds, awards were largely given to public or third
sector organizations, with few commercial premises involved
in the scheme:
Actually there aren’t a great deal of private companies
who have come on board. Obviously a lot of health
CH A L L E NG E S O F WO RK I N G W I T H FO O D O U T L E T S
centres are, the council are very good, and all the children’s centres, they are on board with the system. In
terms of taking it out to your local businesses, that
really is to me the main angst of the scheme (Public
Health staff member, PCT).
Participants responsible for all three initiatives reported that
these were afforded low priority in comparison with the
other elements of their workloads. At the time of the research, the post responsible for the Eat Well Award was
vacant, and no other member of staff was working on the
project in the interim. The Breastfeeding Welcome Award
had operated for a short period only, and that period had
since finished. The Wellbeing Powers of the planning authority had been discussed within the borough but no progress had been made towards their implementation:
Unfortunately due to circumstances – with losing the
officer concerned and in taking time to get the post
advertised so it’s still actually vacant – hence the
delay with this year’s Eat Well Awards (Manager,
Environmental Health, Local Authority).
To be honest, because we have to prioritise, our priorities have been the baby friendly side of things. And although we have had a go at this – it is a piece of work
that really needs more work on it (Public Health staff
member, PCT).
The NHS employees felt that it might be very labour intensive to work with commercial sector organizations. This deterred them from putting in the prolonged effort required to
persuade businesses to adopt the healthier environment
schemes, an approach that was noted by local authority
colleagues:
There are certain people who maybe don’t see the
work involved in the promotion of the service, the
hard work, going out to businesses, trying to get businesses on board. It takes up time, and the end result
may not be what you would want them to say. All that
time for so small a result . . . We know the hard work
that is going into the provision of that service, we see
the staff who are out there trying to get the business
on board, they are spending hours going out actively
promoting what the service is, but at the end of the
day sometimes they don’t get a take-up from
the company (Manager, Environmental Health, Local
Authority).
How can businesses be motivated to participate in
public health initiatives?
It is possible that the staff responsible for the Breastfeeding
Welcome Award and the Eat Well Award found it time
551
consuming and difficult to engage businesses because they
had struggled to align the aims of the Awards with the
motives that drive the commercial sector. Businesses could
be motivated by positive publicity which may increase their
sales. Despite this, neither of the Awards was well publicized
to the public, and—although outlets could display window
stickers—lists of establishments who had received the
Awards were not available to members of the public:
Participant: Well if you rang up we would probably be
able to give that information because we have the
names, obviously, of all the businesses who do have
the awards. So people could come to us and we would
be able to give that information out. But the businesses
they do have a sticker that they can put on display
(Manager, Environmental Health, Local Authority).
As a result of these low publicity levels, it seemed that consumer brand awareness in relation to the Awards was poor.
Aiming too low, or real-world compromise?
The Eat Well Award was given to food outlets that could
demonstrate that they were offering a healthy option on
their menus. They did not have to present an entirely
healthy menu, but needed to offer at least one healthy
choice alongside meeting a range of healthy eating criteria—
for example, having artificial sweeteners available. Cafés and
restaurants were free to continue to serve ‘unhealthy’ food,
meaning that many customers probably did not eat well at
food outlets that had received the Award:
Participant: The Eat Well award is to do with what they
are offering: is it low fat? Is it sugar free? Are you
offering healthy alternatives such as wholemeal bread,
brown rice that type of thing, low fat yoghurts whatever it may be, semi-skimmed milk? A whole host of
things – the preparation: are you using vegetable fats
for cooking? Are you grilling – not deep fat frying?
Things like that. So it’s looking at how things are done
and what the businesses are actually offering: are they
offering a healthier option to the customer?
Interviewer: So does it have to be that the business is
offering a healthier option or does it have to be that
the whole menu complies?
Participant: Well it’s a healthier option if they want the
Award – it’s got to be. They have got to prove that
they are offering a healthier choice,
I mean some people may like their burgers deep fat
fried, so long as they can prove there is an option that
they can be grilled (Manager, Environmental Health,
Local Authority).
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J O U RN A L O F P U B L I C H E A LTH
NHS staff perceived there to be a conflict involved in presenting the Breastfeeding Welcome Award to outlets that
welcomed breastfeeding mothers but served unhealthy food.
They did recognize, however, that in order to create an environment that supported breastfeeding it was desirable to
have as many welcoming outlets as possible:
My dilemma was, we have got certain cafés there, but
they are not particularly healthy cafés. So do you say
‘Right, we exclude you because you sell sausage rolls’?
But that’s what people eat. So that’s a dilemma, but
then I thought ‘No, let’s just ask anyway.’ If that is
where people go, then this is about being welcoming,
and . . . at the end of the day if that’s where people go,
then we should be asking them (Public Health staff
member, PCT).
Discussion
Main finding
The public health staff knew how difficult it could be for
businesses in disadvantaged areas to generate profits and
were sensitive to the potential conflict between health
and commercial success. Working with cafes, restaurants and
takeaway food outlets was perceived to be time consuming,
with many alternative areas of public health work offering
better opportunities for health gain. The two awards that
they were implementing, Eat Well and Breastfeeding
Welcome, faced a major challenge from local culture in an
area where bottle-feeding for infants and fast food were the
norm. At the time of the study, the planning powers to restrict the opening of fast food outlets had not been used.
Limitations
This study describes public health staff perceptions of the
challenges they faced when working with local businesses.
The study area contained high levels of social disadvantage,
amongst a predominantly white population. Hence, the findings may be of most value to the pubic health workforce in
similarly disadvantaged areas. The participants of this study
were selected purposively, and many were identified by more
senior members of staff. Fear of repercussions in the workplace or loyalties to staff or organizations could, in theory,
inhibit full expression of their true views. However, these
concerns do not appear to be supported by the data, which
contain critical and reflective accounts of their work. The
interviews were conducted only with public sector employees. Food retailers’ perceptions of public health approaches
were not captured. This approach was chosen because the
focus of the study was on maximizing the effectiveness of
local public health practice. Tackling the obesogenic environment is a broad aim that requires engagement with a
number of sectors, not just food, but capturing views across
different areas was not possible within available resources
What is already known
Local authorities in England already have the planning
powers needed to control the number of fast food outlets in
an area and national policy encourages their use.18 But in
practice implementation of supplementary planning documents to prevent fast food businesses from opening in close
proximity to schools and leisure facilities is a slow process
and few local authorities have publicized their actions.
(Waltham Forest, in outer London is an exception, and has
described its work in a local government website.)22
Balancing health with the benefits of local employment presents a dilemma to local authorities in disadvantaged areas,
when their members must face re-election every few years.
Nevertheless, evidence from around the world supports the
existence of an association between access to fast food and
socioeconomic differences in diet and obesity.23 – 25 Fast
food consumption amongst children has risen rapidly in the
last two decades, and accounts for an increasing proportion
of the total energy intake of children. Failure to tackle the
growth of fast food outlets risks perpetuating social inequalities in access to healthy food. A better understanding of the
reasons behind local authorities’ reluctance to use planning
powers to regulate fast food is required. It may be that national action on the density and location of outlets would be
a more practical and effective approach.
A range of studies suggests that breastfeeding may
protect against overweight and obesity in later life, but a
paucity of intervention studies and multiple methodological
challenges mean that the evidence is not definitive.16,26,27
Nevertheless, breastfeeding has many other health benefits
and the World Health Organization recommends exclusive
breastfeeding for the first 6 months of life. In the UK, the
initial breastfeeding rates have risen to 81%; in 2010, but
this conceals significant social patterning.15 Mothers who are
better educated, working in professional and managerial
occupations or are older, are more likely to breastfeed.15 An
extensive literature describes strategies to increase initiation
and duration of breastfeeding, Attitudes to breastfeeding in
public have been acknowledged as a barrier.28,29 Yet, there is
relatively little research into interventions targeted at disadvantaged women, or community level initiatives.30 Key attributes of a successful strategy include multi-sectoral working
and having a tailored package of interventions that are
locally appropriate.29 In this study, implementation of the
award did require the former, but it may not have been
the most appropriate intervention for the area, emphasizing
the value of local adaptation of national initiatives.
CH A L L E NG E S O F WO RK I N G W I T H FO O D O U T L E T S
Implications, what this study adds
The new vision of public health outlined in the public
health white paper is in local authorities, with local freedom,
accountability and funding, ensuring that public health is ‘at
the heart of everything that councils do’.31 Such locally appropriate public health action, however, unsupported by
central government, risks being ineffective. In this study,
attempts by public health practitioners to change local business practices would have benefited from more robust national policies. Local health promotion with national fast
fast-food chains was thought to be futile by one participant,
but a more supportive national context could challenge this
assumption. No local authority can compete with commercial advertising budgets, and self-regulation on advertising of
alcohol, for example, has failed.32 The national responsibility
deal ‘pledges’ for alcohol promise to avoid advertising
within 100 m of schools and comply with best practice guidance. If the food industry pledges are similar, they are unlikely to cause much disruption to profits in the digital era.
Voluntary changes that have a minimal impact on profits
seem unlikely to bring about the sizeable changes within the
food industry that are needed to influence trends in the
levels of obesity.
Moving public health into local authorities offers an opportunity to learn from and harness the skills and experience of staff working in environmental health directorates,
local chambers of commerce, and elsewhere, who are
already familiar with the challenges of working with local
businesses. Whether existing relationships concerned with
environmental health will benefit health promotion may
depend on how effectively the different members of the
public health team work together. Food hygiene presents a
more immediate risk to public health than unhealthy eating
choices, but appropriate prioritization should not mean that
longer term action on the obesogenic environment is
neglected. The food industry is a global concern, and expectations of what may be achieved by a small number of staff
within a local authority must be realistic. Robust regulatory
and legislative support at a national level is needed. In the
absence of these, close scrutiny of any voluntary agreements
and evaluation of their effectiveness at influencing the
public health consequences of industry practices will be
essential.
Research ethics approval
Local NHS and University ethics committees advised that
ethical approval was not required for this study as they considered it to be a service evaluation, rather than research
(Personal communication NHS REC North West August
2009)
553
Funding
This work was supported by the NHS organization (former
Primary Care Trust) in the North West of England in which
the research was carried out. This paper represents the
views of the authors, not of the host organization. B.H. is
supported by an NIHR Career Development Fellowship
(NIHR CDF-2009-02-37). The views and opinions
expressed therein are those of the authors and do not necessarily reflect those of the Department of Health.
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