Healthy Lives, Healthy People: A Call to Action on Obesity in England

Healthy Lives Healthy People: A Call to Action on Obesity in England^{( 5 )} (hereafter referred to as ‘the call to action’) is of particular interest to policy makers and public health specialists given its bold and explicit aspirations to achieve both a sustained downward trend in the level of ‘excess weight’ (wording used in ‘the call to action’) in children by 2020 and a downward trend in the level of ‘excess weight’ averaged across all adults by 2020. This ambition was aligned with a strategy of collective engagement and shared responsibility; the policy emphasised roles for a wide range of stakeholders and delivery partners transcending health, social care, local authorities and businesses. Explicitly, ‘the call to action’ aimed to ‘harness the contribution of national partners – including businesses, with creation of responsibility deals, and brokering partnerships with business, civil society and the voluntary sector’^{( 5 )}.

The UK Government has faced several challenges in delivering on its strategy for business to take a ‘leading’ or ‘greater’^{( 5 )} role in obesity prevention and treatment. Here we focus on three interrelated challenges: (i) balancing collaboration while maintaining appropriate distance from industry stakeholders; (ii) resultant production of ‘watertight’ and effective legislation or intervention; and (iii) government’s actual or perceived limited sanctioning or bargaining power. For each of these challenges, we present and critique a specific policy example.

Challenge 1: collaboration without conflict of interest

Concerns about the difficulties of managing business-related conflict of interest in public health policy making are widespread enough for the WHO to require those signed up to its Framework Convention on Tobacco Control to protect health policies from commercial and other vested interests of the tobacco industry^{( 6 )}. In the UK, the exclusion of the tobacco industry from policy environments while simultaneously entering into partnerships with the food and alcohol industries has been criticised⁽ Reference Gilmore, Savell and Collin ^{7 )}. Public–private partnerships are unlikely to be sustained if interests of government (public health) and industry (stakeholder profit) are not equally served⁽ Reference Hawkes and Buse ^{8 ,} Reference Panjwani and Caraher ^{9 )}, which raises issues when these goals are misaligned or directly conflicting.

To elaborate with one specific example, the UK Government’s 2010 Public Health Responsibility Deal^{( 10 )} has been criticised heavily for allowing food and drink brands to have input during its development. Profit motives are explicitly recognised: ‘a sound business case’ to ensure partner commitment is embedded in the logic model of the policy. However, businesses participating have reported doing so not only to meet corporate social responsibility commitments and enhance reputations, but also to reduce the possibility of regulations⁽ Reference Durand, Petticrew and Goulding ^{4 )}. While the former appears worthwhile, such motives are often transient and a reliance on self-regulation has been criticised as ineffective across a range of sectors (e.g. chemical safety⁽ Reference King and Lennox ^{11 )}; tobacco and alcohol⁽ Reference Sharma, Teret and Brownell ^{12 )}). Where this has been effective (e.g. environmental policy), it has been argued that this is only due to the maintenance of genuine legislative threat, external monitoring and sanctions⁽ Reference Héritier and Eckert ^{13 )}. This is not the case with the Public Health Responsibility Deal. Here, arguments that despite their differing motives, government–food industry partnerships would result in an enhanced response (e.g. through better collaboration) are undermined by criticism that eventual outcomes were weak or inappropriate. For instance, Knai et al.⁽ Reference Knai, Petticrew and Durand ^{14 )} analysed the effectiveness of the Public Health Responsibility Deal food pledges – out-of-home energy labelling, salt reduction, energy reduction, front-of-pack nutrition labelling, fruit and vegetable consumption, and saturated fats – reporting that in most cases pledges were already underway, with more structural approaches to improving diet (e.g. food pricing strategies, marketing restrictions) not represented. This is at odds with arguments that wider system change, as opposed to informational interventions targeting individuals, is necessary for public health improvement⁽ Reference Carey and Crammond ^{15 )}. Thus, although the Public Health Responsibility Deal pledges were lauded as representing a genuine commitment from industry partners to improving public health⁽ Reference Durand, Petticrew and Goulding ^{4 )}, in reality organisations continued with business as usual.

A related challenge is that the visible involvement of industry with policy can lead to perceived contradictory messaging and resultant public confusion. For instance, where policy informs that high-sugar products are detrimental to health (e.g. causing diabetes, tooth decay, obesity), brands involved in policy development simultaneously inform the population that their products can be healthy or consumed as part of a healthy lifestyle (e.g. Coca-Cola Co.). The extensive marketing of this message has been criticised as normalising energy-dense nutrient-poor food consumption patterns at societal level⁽ Reference Pettigrew, Tarabashkina and Roberts ^{16 )}. Ultimately, critics⁽ Reference Knai, Petticrew and Durand ^{14 )} argue that the Public Health Responsibility Deal was fundamentally flawed in expecting industry to voluntarily act to improve public health while potentially threatening existing business models. In response to some of this criticism, more recent policy (e.g. Child Obesity: A Plan of Action) adopts a more robust approach by, for example, including taxation penalties for high-sugar products. Appropriately developing and enforcing such legislation, however, has been another key challenge for Government.

Challenge 2: developing robust legislation and regulation

Private partners involved in UK obesity-related policy openly declared their hopes to reduce the possibility of regulation⁽ Reference Durand, Petticrew and Goulding ^{4 )}, and where this was not possible, it was perhaps inevitable that companies lobbied for strategies to ‘soften’ regulation (e.g. reducing targets or penalties for non-compliance). This issue can be demonstrated by viewing the recent UK Government’s Soft Drinks Industry Levy (SDIL)^{( 17 )}, more commonly known as a ‘sugar tax’. The SDIL is a policy that ‘will help to reduce sugar in soft drinks and tackle childhood obesity’^{( 17 )}. Intended to reduce the sugar content of products as well as reduce portion sizes, in many instances industry response has focused on the latter mechanism as opposed to product reformulation. This might risk greater product consumption through lower satiety and therefore no change in the ultimate volume of sugar consumed.

It is unlikely that the Government would not have considered that industry might not reformulate and thus reduce the sugar content within products. It is also unlikely that it would not have considered that companies could and would opt to merely absorb the tax themselves or increase the price of their product to cover this loss. Adopting softer approaches (e.g. a tax as opposed to regulating a maximum level) enabled the UK Government to maintain positive relationships with industry, but undermined policy aims. Even strong legislation or regulatory standards are not enough; we must also have a government willing and able to follow through with appropriate sanctions to drive compliance⁽ Reference Knai, Petticrew and Durand ^{14 )}. This highlights a final underlying challenge for Government – how far it is willing to push industry?

Challenge 3: a perception of limited sanctioning and bargaining power

Government appears in a difficult negotiating position when trying to encourage or enforce obesity-related action. Food and drink industry brands bring many benefits to the UK including contributions to gross domestic product, employment, and wider investment and sponsorship (e.g. of major events). Collaborative working and genuine ‘buy-in’ from industry could accelerate the pace of public health improvement; however, history informs that in relation to public health intervention, pursuing partnerships rather than adopting a stronger governance approach reduces effectiveness of policy strategies (e.g. see effects of cutting ties with tobacco industry). We argue that currently Government is failing in its responsibility to the public by prioritising protection against potential loss of economic or employment-related benefits from industry over actual and current damage that existing practice has on public health.

One area where some progress is being made is regarding marketing of unhealthy foods and drinks. For instance, the WHO Commission on Ending Childhood Obesity^{( 18 )} and Recommendations for Food Marketing and Non-Alcoholic Beverages^{( 19 )} both advocate minimising children’s exposure to the marketing of ‘foods that are high in saturated fats, trans-fatty acids, free sugars, or salt’ (p. 8)^{( 19 )}. In the UK, policy relating to the marketing of unhealthy foods and drinks focuses on media placement restrictions and advertisements for high fat, salt or sugar products. While commendable for attempting to limit the presence and influence of industry messaging, policy could again have been strengthened. For example, Government has yet to adopt the All-Party Parliamentary Group on Obesity’s recommendations that government ‘implement a 9 pm watershed on advertisement of food and drink high in fat, sugar and salt’^{( 20 )} and enforcement opportunities actioned elsewhere have not been implemented⁽ Reference Flint and McKenna ^{21 )}.

Where next?

Relatively little progress in reducing ‘excess weight’ has been made during the seven years since ‘the call to action’ on obesity in England was released. We argue that this is at least partially attributed to industry involvement in policy, resulting in weak action. We recommend: increased use of legislative powers; limiting industry influence in government; and recognising and appropriately rewarding industry behaviour that benefits public health.

1. 1. History tells us that self-regulation among the food and drink industry does not meet public health objectives⁽ Reference Knai, Lobstein and Petticrew ^{22 )} and government involvement counts for little in the absence of sanctions to drive compliance⁽ Reference Knai, Petticrew and Durand ^{14 )}. There is a need therefore to move beyond expectations and requests for industry to voluntarily self-regulate, and instead mandate changes that reduce the abundance of unhealthy food and drink products in society. Legislation should be used more widely and effectively across a range of areas including food content, labelling and advertising. Methods available include imposing enforceable duties on bodies in a position to improve public health, and creating or expanding licensing, taxation and inspection powers to create leverage⁽ Reference Martin ^{23 )}.

2. 2. Industry influence in policy making must be limited. Consider what we can learn from the reduction of industry involvement in other public health topics. There was once a time when tobacco companies would have a seat at the top table to contribute to smoking cessation efforts; this did not work, and it was only once industry involvement decreased that smoking cessation strategies became more effective. Genuine partnerships or incentives for business can be maintained where the public health objective is prioritised foremost (e.g. the Diet and Health Research Industry Club – government and industry research for new or reformulated foods)^{( 24 )}. It is also suggested that public health objectives are set prior to any potential partnership⁽ Reference Gilmore, Savell and Collin ^{7 )} and that partnerships do not provide opportunities for renegotiation of objectives, as observed in the Public Health Responsibility Deal⁽ Reference Petticrew, Eastmure and Mays ^{25 )}.

3. 3. Finally, bold action that celebrates and supports the promotion of public health should be observed. There is a focus on identifying and criticising unhealthy food and drink companies – and rightly so – but we rarely see celebration of companies that develop, provide and support healthy behaviours. Government should provide financial and trading incentives for industries promoting population health, and in doing so, provide profit-based incentives for other industry to follow suit.