Profit versus public health: the need to improve the food environment in recreational facilities.

Olstad, Dana Lee ; Raine, Kim D.

A growing body of literature documents the problem of the ubiquitous availability of unhealthy foods in recreational facilities (1-6) and other sport settings. (7) This is of concern because unhealthy food environments negatively impact children's dietary behaviours and body weights. (8-10) To address this problem, several Canadian provinces have developed formal nutrition guidelines (British Columbia and Alberta), incentive-based programs (Ontario), toolkits (British Columbia, Ontario, Manitoba, Saskatchewan, New Brunswick) and other printed and online resources for the recreation sector. (11) Uptake of Alberta's Nutrition Guidelines for Children and Youth (ANGCY), (12) in particular, has been limited, with only 6% of facilities surveyed reporting that they had implemented them one year following their release. (3) Financial constraints appear to be the most important barrier to offering healthier items in Alberta's recreational facilities, as managers perceive that selling healthier foods is unprofitable. (4,13) Managers play a gatekeeping role in recreational facility food services, and thus it is particularly important to target their knowledge, beliefs and perceptions of nutrition guidelines. (4)

On the basis of these findings, we designed an intervention to overcome some of the barriers to offering healthier foods in recreational facilities, and specifically to stimulate uptake of the ANGCY. The study was intended to positively impact managers' knowledge, beliefs and perceptions of nutrition guidelines through: 1) participation in a one-day training session to learn about the ANGCY and strategies to offer healthier items without losing revenue, and

2) interaction, through five monthly group meetings, with other managers who were successfully using nutrition guidelines. Notably, managers were assured in advance that they would be free to decide how and to what extent to comply with ANGCY recommendations to offer healthier items within their food services. However, despite a lengthy recruiting process facilitated by provincial recreation associations (reach of >1,400 individuals) and Health Promotion Coordinators in communities across the province, the study had to be cancelled due to low enrollment.

The challenge to incent preferential sale of healthier foods in recreational facilities is clearly substantial. Although other factors such as the time commitment associated with study participation were likely influential, comments from managers who declined to participate and results from past Canadian investigations (2-6,13-15) suggest that the barriers to study participation were primarily financially driven. Recreational facility and food service managers felt compelled to generate a profit, but perceived that selling healthier foods as part of the study would be unprofitable, and might jeopardize sponsorship agreements with beverage companies. Economos et al. (16) encountered similar challenges recruiting restaurant managers into an initiative to increase availability of healthier options. By contrast, although similar barriers existed in BC recreational facilities, a pilot study of 10 facilities proceeded. (5) It is likely that availability of seed funding and substantial implementation resources supported participation in that study, although improvements to recreational facility food environments were limited even within that supportive context. (5)

In general, voluntary guidelines have proven relatively ineffective in encouraging provision of healthier items by the food industry. (17) Similarly, evidence indicates that voluntary guidelines may be ineffective in encouraging meaningful change in recreational facility food environments. (3-5,13) Mandatory government regulation may therefore be required to ensure that recreational facilities support child health and do not undermine it by exposing children to overwhelmingly unhealthy food environments. Prior to enacting regulations, however, it is important to consider their potential positive and negative consequences to ensure a reasonably equitable distribution of costs and benefits.

Potential advantages

1) Policies mandating provision of primarily or exclusively healthier foods in recreational facilities within specific and short time frames are virtually certain to increase these foods' availability in an efficient manner, provided that policies are enforced. Such policies are associated with improved dietary behaviours and body weight in children, (18) and thus regulation would contribute to important public health objectives. If enacted in multiple settings (e.g., schools, childcare, government buildings), regulations might furthermore incent food reformulation by industry, (19,20) providing healthier default options for all consumers and yielding more widespread health benefits. By improving population health, regulations could also benefit industry by providing a productive workforce to produce and deliver the goods and services they sell, a healthy clientele to purchase them, and a productive economic climate within which to operate.

2) Currently, governments provide partial funding to recreational facilities in support of healthy living, yet actively undermine their own efforts by allowing unhealthy foods to predominate there. Regulations that increase availability of healthier items and curtail availability of unhealthy items would resolve this paradoxical conflict. Coherent policy would furthermore project a consistent message to children that healthy eating and physical activity go hand in hand.

3) Regulations are an equitable means of addressing the problem of unhealthy food environments in recreational facilities. Universal regulations would create a level playing field for businesses that provide food services within recreational facilities, reducing the risks associated with compliance. Regulations could also help to correct the unequal distribution of costs and benefits associated with the sale and consumption of unhealthy foods, whereby the benefits primarily accrue to industry while the costs are largely borne by the public.

Potential disadvantages

1) Corporate profitability might be negatively impacted if, as industry contends, few consumers will purchase healthier items despite increased availability. (13) In reality, however, there is no reason why selling healthier foods cannot be a profitable venture for industry. Indeed, the food industry controls the food supply, and not only responds to but actively shapes consumer demand for its products through marketing. Were it to leverage its vast wealth and resources to develop and market healthier items, it would almost certainly succeed in increasing their sale and consumption. Even scientists with comparatively limited resources have succeeded in doing so. (21) The problem is not that healthy items are not profitable, but that industry has so far lacked the incentive to make them so.

2) While critics contend that government regulation would limit freedom of choice, given the preponderance and extensive marketing of unhealthy foods in recreational facilities, it is difficult to argue that the current environment supports free and independent food purchasing decisions. Therefore, increased or exclusive availability of healthier foods in recreational facilities would not further constrain choice, but would merely change the content of the limited choice that currently exists.

Governments regulate food to ensure its microbial safety and mandate food fortification to prevent nutritional deficiencies because society acknowledges that food choice must sometimes be curtailed to protect public health. In developed nations, morbidity and mortality attributable to unhealthy diets greatly exceed that attributable to food-borne pathogens and toxins. Therefore, just as regulations prevent industry from purposely selling and marketing foods that are unsafe for microbial reasons, so too should it not be permitted to sell and market foods that are unsafe for nutritional reasons, particularly in venues where children gather, such as recreational facilities. Failure to limit children's access to nutritionally unsafe foods constitutes a violation of society's ethical obligations to protect children.

Development and implementation of regulations

Unhealthy food environments in recreational facilities are an unintended negative consequence of policies designed to improve access to affordable physical activities by using food service revenues to partially subsidize lower user fees. Regulations are not a panacea, however judicious use of government power to regulate food availability in recreational facilities can redress the aforementioned oversight and appears advantageous. Although this discussion has focused on children, as they represent the majority of recreational facility users, adults who use recreational facilities may also benefit from regulations.

Regulations should be developed in consultation with all stakeholders, considering each sector's capacities and constraints, while being careful not to allow the economically powerful voice of industry to take precedence over public health concerns. The final regulations should be child-focused, include robust standards for what constitutes a healthy food/beverage (i.e., standards should not merely lead to production of healthier junk foods), mandate that a high proportion of items be healthy, prohibit marketing of unhealthy foods, and ensure healthier items are affordable in recreational facilities.

Implementation of regulations will be challenging, as adults who frequent recreational facilities and industry may raise some of the aforementioned objections. It will furthermore take time to denormalize the culture of unhealthy eating that exists. Substantial implementation support will be essential to address these challenges, and regulations should be phased in over several years to provide an adjustment period.

CONCLUSION

Government regulation of food availability in recreational facilities appears to offer an efficient, effective and equitable means of aligning the financial interests of the food industry with public health goals. Clearly, these regulations will not solve the complex problem of childhood obesity. Nevertheless, each eating occasion represents an opportunity to influence health, for better or worse. The food environment within recreational facilities is part of a broader context of unhealthy food environments that reinforces a culture of unhealthy eating, detracts from efforts to reverse it, and is a source of contradictory messages. Action to improve recreational facility food environments will help facilities to achieve their wellness mandate, while contributing to a broader culture of healthy eating across societal sectors and settings.

Acknowledgements: The authors thank Dr. Timothy Caulfield for his contribution to conceptualization of the commentary.

Conflict of Interest: DLO and KDR were members of the committee that prepared the literature review and draft version of the Alberta Nutrition Guidelines for Children and Youth, which was funded by the Government of Alberta. The authors have no other competing interests.

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Received: September 20, 2012

Accepted: December 8, 2012

Dana Lee Olstad, MSc, RD, [1-3] Kim D. Raine, PhD, RD [1,3]

Author Affiliations

[1.] Alberta Institute for Human Nutrition, University of Alberta, Edmonton, AB

[2.] Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental Sciences, University of Alberta, Edmonton, AB

[3.] Centre for Health Promotion Studies, School of Public Health, University of Alberta, Edmonton, AB

Correspondence: Dana Olstad, 4-10 Agriculture/Forestry Centre, University

of Alberta, Edmonton, AB T6G 2P5, Tel: 780-492-2064, Fax: 780-492-0364, E-mail: dana.olstad@ualberta.ca

Funding: Our research program in recreational facilities has been funded by the Canadian Institutes of Health Research (CIHR) and the Canadian Foundation for Dietetic Research. These organizations had no role in study design, in the collection, analysis, and interpretation of data, in the writing of the report, or in the decision to submit the report for publication. Dana Olstad has received scholarship support from a Vanier Canada Graduate Scholarship, a CIHR/Heart and Stroke Foundation Training Grant in Population Intervention for Chronic Disease Prevention, the Canadian Federation of University Women, the Women and Children's Health Research Institute/Alberta Diabetes Institute, Dietitians of Canada and the University of Alberta. Kim Raine is funded by a CIHR/Heart and Stroke Foundation Applied Public Health Chair.