Obesity And The Environment: Regulating The Growth Of Fast Food Outlets
Healthy people, healthy places briefingObesity and the environment:regulating the growth of fastfood outletsMarch 2014
Obesity and the environment: regulating the growth of fast food outletsAbout PHEPublic Health England’s mission is to protect and improve the nation’s health and to address inequalitiesthrough working with national and local government, the NHS, industry and the voluntary andcommunity sector. PHE is an operationally autonomous executive agency of the Department of Health. Crown copyright 2013You may re-use this information (excluding logos) free of charge in any format or medium, underthe terms of the Open Government Licence v2.0. To view this licence, visit OGL or email psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will needto obtain permission from the copyright holders concerned.About this briefingThis briefing has been written in conjunction with the Local Government Association (LGA) and theChartered Institute of Environmental Health (CIEH). It is aimed at those who work in or represent localauthorities. It addresses the opportunities to limit the number of fast food takeaways (primarily hotfood takeaways, especially near schools) and ways in which fast food offers can be made healthier.It summarises the importance of action on obesity and a specific focus on fast food takeaways, andoutlines the regulatory and other approaches that can be taken at local level.This briefing was written for PHE by Dr Nick Cavill and Professor Harry Rutter.We would like to thank all those on our advisory group who commented on the drafts of this briefing,with special thanks to Angela Hands, public health practitioner, planning and transport, Coventry CityCouncil and Andrew Ross, writer and editor, Final Draft Consulting for their additional expert advice.We would welcome your views on this briefing and how we might develop or improve these in future. Ifyou have ideas for future topics, let us know. Enquiries to Healthypeople.healthyplaces@phe.gov.ukContents1. The importance of action on obesity32. The role of the environment33. Planning and health: the policy context34. Evidence for action on obesity45. What tools are available?56. Ideas for action8Additional resources10References11Revisions, March 2014: page 6, reference to National Planning Practice Guidance; page 7, rewordingabout health considerations in planning appeals. Original version published November 20132
Obesity and the environment: regulating the growth of fast food outletsObesity and the environment:regulating the growth of fastfood outlets1. The importance of action on obesityIn 2011 the government published ‘Healthylives, healthy people: a call to action onobesity in England’,1 which described thescale of the obesity epidemic and set outplans for action across England.*Obesity impacts on health in many ways. Itis a cause of chronic disease leading to earlydeath. It increases the risk of type 2 diabetes(fivefold in men and twelvefold in women),raised blood pressure (two and four timesrespectively) and colorectal cancer (three andtwo times respectively).2Two-thirds of English adults, one fifth ofchildren in reception (four to five years old),and a third in year 6 (ten to 11 years) areobese or overweight.2,3 Obesity tends totrack into adulthood, so obese children aremore likely to become obese adults.3There are stark inequalities in obesity ratesbetween different socioeconomic groups:among children in reception and year 6,the prevalence of obesity in the 10% mostdeprived groups is approximately double thatin the 10% least deprived.2. The role of the environmentThe 2007 UK government Foresight report‘Tackling obesities: future choices’4 remainsthe most comprehensive investigationinto obesity and its causes. It described* In adults, obesity is commonly defined as a body mass index (BMI) of 30 ormore. BMI is weight (in KG) divided by the square of height (in metres). Forchildren in the UK, the British 1990 growth reference charts are used to defineweight status. See www.noo.org.uk/NOO about obesity for detailsthe complex relations between the social,economic and physical environmentsand individual factors that underlie thedevelopment of obesity.Obesity is a complex problem that requiresaction from individuals and society acrossmultiple sectors. One important action is tomodify the environment so that it does notpromote sedentary behaviour or provideeasy access to energy-dense food.5 Theaim is to help make the healthy choice theeasy choice via environmental change andaction at population and individual levels.This provides the opportunity to build thepartnerships that are important for creatinghealthier places, and around which localleaders and communities can engage.6Local authorities have a range of legislativeand policy levers at their disposal, alongsidewider influences on healthy lifestyles, thatcan help to create places where people aresupported to maintain a healthy weight.Public health professionals should work withtheir colleagues across local authorities touse these and other approaches to maximisehealth benefits.3. Planning and health: the policycontextPlanning authorities can influence the builtenvironment to improve health and reducethe extent to which it promotes obesity.7,8The government’s public health strategy‘Healthy lives, healthy people’, explicitlyrecognises that “health considerations are3
Obesity and the environment: regulating the growth of fast food outletsan important part of planning policy”,1 andthe Department of the Environment 2011white paper made many explicit connectionsbetween planning and health.9 One of theten recommendations of the Academy ofMedical Royal Colleges’ 2013 report onobesity was that “Public Health Englandshould, in its first 18 months of operation,undertake an audit of local authority licensingand catering arrangements with the intentionof developing formal recommendations onreducing the proximity of fast food outletsto schools, colleges, leisure centres andother places where children gather”.10 It alsorecommended that local authority planningdecisions should be subject to a healthimpact assessment.PHE’s obesity knowledge and informationteam (formerly the National ObesityObservatory) has produced a briefingpaper on fast food outlets, together withdownloadable data on fast food outletsby local authority. This shows the densityof outlets varies between 15 and 172 per100,000 population (see below).This data shows a strong associationbetween deprivation and the density offast food outlets, with more deprived areashaving a higher proportion of fast foodoutlets per head of population than others.4. Evidence for action on obesityThe typical adult diet exceedsrecommended dietary levels of sugar andfat. Less than a third of adults currentlymeet the five a day target and aroundone in five children aged five to 15 meetsthe target, with the average being justthree portions a day.11 Healthy eating isassociated with a reduced risk of beingoverweight or obesity and of chronicdiseases, including type 2 diabetes,hypertension, and certain cancers.12One of the dietary trends in recent years hasbeen an increase in the proportion of foodeaten outside the home, which is more likelyto be high in calories.4 Of particular concernare hot food takeaways, which tend to sellfood that is high in fat and salt, and low infibre, fruit and vegetables.13Research into the link between foodavailability and obesity is still relativelyundeveloped14 although a US study hasfound evidence of elevated levels of obesityin communities with high concentrations offast food outlets.15School foodChildren who eat school meals tend toconsume a healthier diet than those who eatpacked lunches or takeaway meals.17 Whilethere have been many initiatives to improvestandards of school meals, including nutrientbased standards and the School Food Plan,these currently only affect around four in tenchildren who take school meals.4,18,19 Uptakeof school meals decreases when childrenmove from primary to secondary school(46.3% compared to 39.8%), and in many4
Obesity and the environment: regulating the growth of fast food outletscases secondary school pupils are allowedto leave the school premises at lunchtime.Improving the quality of the food environmentaround schools has the potential to influencechildren’s food-purchasing habits, potentiallyinfluencing their future diets.19 However, it isimportant to note that taking action on hotfood takeaways is only part of the solution,as it does not address sweets and otherhigh-calorie food that children can buy inshops near schools.Action on the food environment is supportedby the NICE public health guidance,‘Prevention of Cardiovascular Disease’.20NICE recommends encouraging planningauthorities “to restrict planning permissionfor takeaways and other food retail outletsin specific areas (for example, within walkingdistance of schools)”.It is only in recent years that local authoritieshave started to use the legal and planningsystems to regulate the growth of fastfood restaurants, including those nearschools. There is thus an unavoidablelack of evidence that can demonstrate acausal link between actions and outcomes,although there is some limited evidenceof associations between obesity and fastfood,21 as well as with interventions toencourage children to stay in school forlunch.13 However, there are strong theoreticalarguments for the value of restricting thegrowth in fast food outlets, and the complexnature of obesity is such that it is unlikely anysingle intervention would make a measurabledifference to outcomes on its own.There are several reasons why the presenceof fast food outlets may be undesirable froma public health perspective, with implicationsfor planners. For example: many hot food takeaways may generatesubstantial litter in an area well beyond theirimmediate vicinity discarded food waste and litter attractsforaging animals and pest species hot food takeaways may reduce thevisual appeal of the local environment andgenerate night-time noise short-term car parking outside takeawaysmay contribute to traffic congestion improving access to healthier food indeprived communities may contribute toreducing health inequalitiesThe most relevant evidence of successfulapproaches in England tends to come fromcase studies of approaches being taken bylocal authorities using policy and regulatoryapproaches.5. What tools are available?The ‘Takeaways toolkit’13 noted that therewere three broad approaches that couldbe taken to address the problem of overproliferation of hot-food takeaways in citycentres and near schools: working with the takeaway businesses andfood industry to make food healthier working with schools to reduce fast foodconsumed by children using regulatory and planning measuresto address the proliferation of hot foodtakeawaysThis briefing focuses on the role of planningon the food environment and so addressesonly the last of these approaches.5
Obesity and the environment: regulating the growth of fast food outletsPlanning lawsThe National Planning Policy Framework(NPPF) makes it clear that local planningauthorities (LPAs) have a responsibility topromote healthy communities.8 Local plansshould “take account of and support localstrategies to improve health, social andcultural wellbeing for all”.The ‘Use Classes’ order defines commercialpremises using a coding system. Therefore,A5 hot-food takeaway premises are definedas “where the existing primary purpose is thesale of hot food to take away”. A3 premisesare “restaurants where the primary purposeis the sale and consumption of food and lightrefreshment on the premises”.22LPAs should prepare planning policiesand take decisions to achieve places thatpromote “strong neighbourhood centres andactive street frontages which bring togetherthose who work, live and play in the vicinity”.However, before 2005 all hot foodtakeaways were given Use of Class A3,when the 1987 Town and Country Planning(Use Classes) Order was amended. Thismeans that, historically, hot food takeawaysmay have given planning permissionunder either Use Class A3 if they havebeen in existence since before 2005 orA5 if permission came after that date.This is important when considering overconcentration or cumulative impact inparticular areas. Also, A3 premises can haveancillary A5 use – that is a restaurant thatalso provides hot food takeaways.The NPPF also gives clear advice that localplanning authorities should “work with publichealth leads and organisations to understandand take account of the health status andneeds of the local population includingexpected changes, and any informationabout relevant barriers to improving healthand wellbeing”.The National Planning Practice Guidance(NPPG)* refers to promoting access tohealthier food and that a health impactassessment** may be a useful tool wheresignificant impact is expected.A number of local authorities*** have drawnup supplementary planning documents(SPDs) to restrict the development of newfast food premises near schools. However,it is recognised that due to consultation andother procedures,these can take a long timeto prepare and agree. SPDs must also relateto a policy in the local plan, so the priority isto make sure the issue is addressed withinthe local plan in the first lth Impact Assessment (HIA)assesses the health impact of policies, plansand projects in diverse economic sectors using quantitative, qualitative andparticipatory techniques: www.hiagateway.org.uk; www.who.int/hia/en/*** Within London, the following councils have been identified to have eitherproposed or adopted restrictive policies based around A5 usage: Barking andDagenham; Greenwich; Hackney, Haringey; Havering; Islington, Kensingtonand Chelsea; Kingston-upon-Thames; Newham and Waltham ForestPlanning permission is required for changeof use to a different category but notchange of use within the same category,although changes in permitted developmentrights that arose in June 2013 mean thatclarification is being sought on this issue.Proximity to schools used as a criterionSt Helen’s Council has implemented awide-ranging policy including a numberof restrictions, granting planning approvalonly “within identified centres, or beyond a400m exclusion zone around any primaryor secondary school and sixth form collegeeither within or outside local educationauthority control”.23 The council’s SPD isa material consideration in determiningplanning applications. As well as proximity toschools and health impact, it covers issuessuch as over-concentration and clustering,highway safety, cooking smells, and litter.6
Obesity and the environment: regulating the growth of fast food outletsMost authorities have used a distance of400m to define the boundaries of their fastfood exclusion zone, as this is thought toequate to a walking time of approximately fiveminutes.24 However, in Brighton and Hovethis was found to be inadequate to coverthe areas actually used by pupils: an 800mradius is used as it covers significantly morelunchtime journeys.Development plan or supplementaryplan documentsBarking and Dagenham was nearingcompletion of its core strategy when itbegan to develop its A5 SPD, which wasadopted in 2010. The council chose todevelop its A5 policy as an SPD, buthas reported that for local authoritiesdeveloping local plans it is advisableto incorporate A5 policies within thedevelopment plan documents (DPD) ratherthan SPDs as they carry more policyweight. The downside of this is that DPDsface much more in the way of proceduralchallenges.25Planning permission/appealsA number of authorities have had planningdecisions challenged through the appealsprocess. Some appeals have been allowed,but many have been dismissed. Healthyeating and proximity to a school has beena consideration in a number of planningappeals.26 It has not been the sole ordetermining factor in the final decision sofar, except for one occasion* we know of.However, healthy eating and proximity to aschool have been given substantial weightwhen there is an adopted local plan policy orSPD in place, local evidence on childhoodobesity and healthy eating initiatives, andrepresentations from the relevant school.*Appeal ref: APP/G5750/A/12/2182393 – London Borough of Newham(December 2012)Can proximity to schools be aconsideration?In 2010 a High Court judge declared thatTower Hamlets Council in East London“acted unlawfully” when it gave the goahead for Fried & Fabulous to open forbusiness close to a school. The judge saidcouncillors had voted in favour of permissionafter being wrongly directed that they couldnot take account of the proximity of the localsecondary school because it was not “amaterial planning consideration”.27However, planning permission wasultimately granted on appeal for a numberof reasons, including the lack of evidencethat “the location of a single take-awaywithin walking distance of schools has adirect correlation with childhood obesity, orwould undermine school healthier eatingpolicies”. This prompted Tower Hamlets toreview its policies with the aim of limitingsuch appeals in future.The importance of engaging withstakeholdersSandwell Council adopted an SPD for hotfood takeaways in 2012, including a 400mexclusion zone around secondary schools,and tests for over-concentration, clusteringand environmental impact. In one appealthere was little support from the schoolaffected or secondary evidence, so theapplication was approved. Council officersreported they have since made effortsto work more closely with public healthcolleagues and to engage with schools onthe issue.28All subsequent appeals to the PlanningInspectorate, including one within 400m ofa secondary school, have been dismissed,so the SPD appears to have beeneffective.297
Obesity and the environment: regulating the growth of fast food outletsEnvironmental health and licensingAlongside planning policies, there are othermeasures available, mainly implemented byenvironmental health or licensing teams, tohelp local authorities regulate the sale of fastfood. These include:different food categories,30 and sit alongsideDH guidance on healthier, more sustainablecatering.31 The government’s ResponsibilityDeal also offers a wide range of advice forsmall businesses on issues, including calorielabelling and reducing saturated fat.32 street trading policies to restrict tradingIn London, the Healthier CateringCommitment is a voluntary scheme forfood outlets, operating across 25 Londonboroughs by catering businesses inpartnership with environmental health andpublic health teams. It provides informationon healthier food together with offeringhealthier alternatives.33from fast food vans near schools policies to ensure that menus providehealthier options enforcement on other issues such asdisposal of fat, storage of waste, and litter food safety controls and compliance restrictions on opening times using Section 106 agreements andthe Community Infrastructure Levy tocontribute to work on tackling the healthimpacts of fast food outletsNo iceHillingdon Council passed a resolutionbanning ice cream vans from the vicinity ofschools and nurseries. One of the reasonscited for the ban was that ice creamtrading near schools contradicted dietaryrecommendations and the aims of theHealthy Hillingdon Schools Scheme.7,13Encouraging healthier provisionAs an alternative to using legislation to restrictthe proliferation of fast food takeaways, localauthorities may choose to work with them tochange the nature of their food provision.The government procurement standardsfor food and catering services aim to setstandards for more sustainable and healthierfood provision. They provide criteria toreduce the salt, fat and sugar content of6. Ideas for actionPublic health professionals and others whowish to address the prevalence of fast foodoutlets in their area in order to supporthealthier lifestyles may find the followingactions helpful:7Strategic leadership: local authority andhealth and wellbeing boards identify a councillor who will be a championon behalf of the local authority and provideleadership (and in two tier areas, to engagewith work with district councillors) work with key partners: local authoritypublic health teams and clinicalcommissioning groups, to identify a seniorlead officer with responsibility for this workwho will champion it within the health andwellbeing board work with other professional groups toidentify lead officers, such as environmentalhealth practitioners, to support this workearly on, especially in two-tier authoritiesthat may otherwise not be directly involved in addition to statutory consultees,ensure the engagement of planners and8
Obesity and the environment: regulating the growth of fast food outletsenvironmental health practitioners as earlyas possible when developing a policywork with planners and other local authoritycolleagues to ensure that appropriate andimportant information is recorded.Public health teams identify a person within the public healthteam to liaise with planning officers establish a programme of health impactassessment (HIA) training for public healthteams, planning officers, and others agree a process with the planning teamfor incorporating HIAs in the planningprocess. Some councils are writingsuch requirements into their assessmentprocesses for planning or developmentapplications over a certain size or scale use government buying standards forfood and catering services as the basis forschool food procurement conduct wider community engagement toincorporate the views of local residents,community groups and schools in planningdecisionsSupporting data and informationPlanning officers will require evidence beforeincluding items in the development plan orSPD so: review all the publications in the ‘additionalresources section’. These contain detailedadvice and case studies consider collecting other data such assurveys of school children’s purchasinghabits on the way to and from schoolEvaluationLocal authorities are required by law topublish an annual monitoring report. This is anexcellent source of information on the impactof policies. Public health colleagues should9
Obesity and the environment: regulating the growth of fast food outletsAdditional resources‘Takeaways toolkit’. A comprehensive briefingincluding tools, interventions and case studiesto help local authorities develop a responseto the health impact of fast food takeaways.Published in 2012 (updated in June 2013)by the London Food Board and CharteredInstitute of Environmental Health, basedon a consultancy report by Food Matters.Available from www.foodvision.cieh.org/document/view/326‘Fast food saturation’. A resource pack thatcollates good practice and key resourcesfrom across London and beyond onmanaging the impact of fast food shops onlocal health and wellbeing through the useof planning powers. Although developedfor use in London, it is based on the use ofnational powers for local authorities and isdirectly applicable in all local areas in England.Published in July 2103 by the London HealthInequalities Network. Available from www.lho.org.uk/viewResource.aspx?id 18208contains a very useful review of the evidenceand case studies on successful approachesto date. Published in 2011 by Brighton andHove City Council and NHS Sussex. Availablefrom k/files/downloads/ldf/Healthy eating Study-25-01-12.pdfThe UK Health Forum’s website containsa wealth of useful information on thefood environment, including an extensiveresource on marketing food to children.www.ukhealthforum.org.uk and Tackling the takeaways: a new policy toaddress fast-food outlets in Tower Hamlets’.This is a wide-ranging evidence review on theassociation between the over-concentrationof hot-food takeaways and obesity, and anexamination of practice (mainly in London).The evidence review and policy backgroundare very comprehensive and will be likely tobe very useful for drawing up policy options.Published in 2011 by NHS Tower Hamlets.Available from www.towerhamlets.gov.uk/i doc.ashx?docid 2b285be6-99434fec-a762- 76c93d07ca50&version -1‘Hot-food takeaways near schools; an impactstudy on takeaways near secondary schoolsin Brighton and Hove’. This assesses thepolicy options for Brighton and Hove, but10
Obesity and the environment: regulating the growth of fast food 15.16.17.Department of Health. Healthy Lives, Healthy People: aCall to Action on Obesity in England. London: Departmentof Health 2011.The Information Centre. Statistics on Obesity, PhysicalActivity and Diet. England 2013.Maffeis C, Tato L. Long-term effects of childhood obesityon morbidity and mortality. Horm Res. [Review]. 2001;55Suppl 1:42-5.Butland B, Jebb S, Kopelman P, McPherson K, Thomas S,Mardell J, et al. Tacking obesities: future choices – projectreport. London 2007.Lake A, Townshend T. Obesogenic environments:exploring the built and food environments. J R Soc PromotHealth. [Research Support, Non-U.S. Gov’t Review]. 2006Nov;126(6):262-7.London Health Inequalities Network. Fast food saturation –a resource pack for London. London 2013.Dr Foster Intelligence and Land Use Consultants. Tacklingthe takeaways: a new policy to address fast-food outlets inTower Hamlets. London 2011.Department for Communities and Local Government.National Planning Policy Framework. London 2012.Department of the Environment. The natural choice:securing the value of nature. London 2011.Academy of Royal Medical Colleges. Measuring up. Themedical profession’s prescription for the nation’s obesitycrisis. Academy of Medical Royal Colleges 2013.National Obesity Observatory. Determinants of obesity:child diet. 2012. www.noo.org.uk/uploads/doc/vid 14864 NOOchilddiet2012.pdfPublic Health England. About obesity 2013. www.noo.org.uk/NOO about obesity/lifestyleLondon Food Board and Chartered Institute ofEnvironmental Health. Takeaways toolkit. A London FoodBoard and Chartered Institute of Environmental Healthpublication based on a consultancy report by FoodMatters. London 2012.Townshend T, Lake AA. Obesogenic urban form: theory,policy and practice. Health & place. [Review]. 2009Dec;15(4):909-16.Zenk SN, Schulz AJ, Odoms-Young AM. Howneighborhood environments contribute to obesity. TheAmerican journal of nursing. 2009 Jul;109(7):61-4.National Obesity Observatory. Obesity and theenvironment: fast food outlets. 2012. www.noo.org.uk/uploads/doc/vid 15683 FastFoodOutletMap2.pdfStevens L, Nelson M. The contribution of school meals andpacked lunch to food consumption and nutrient intakes UK primary school children from a low income population.Journal of human nutrition and dietetics: the official journalof the British Dietetic Association. [Comparative StudyResearch Support, non-U.S. Gov’t]. 2011 Jun;24(3):22332.School Food Plan. 2013. www.schoolfoodplan.com/School Food Trust. Take up of school lunches in England2011-2012. London 2012.National Institute for Health and Clinical Excellence.Prevention of cardiovascular disease. London 2010.Kruger DJ, Greenberg E, Murphy JB, Difazio LA, YouraKR. Local concentration of fast food outlets Is associatedwith poor nutrition and obesity. American journal of healthpromotion: AJHP. 2013 Aug 13.Portal P. Change of use; planning permission. ojects/changeofuseSt Helens Council. Supplementary planning document: hotfood takeaways. 2011.Homes and communities agency. Urban designcompendium 2006.Naomi Pomfret (planning policy manager). Personalcommunication. 2013.Andrew Ross. Personal communication. FD Consultancy2013.Press Association. High Court quashes plan for fast foodoutlet near ‘healthy eating’ school. The Guardian. 201011 June 2010.Stephen Leigh (planning officer). Personal communication.2013.Stephen Leigh. Planning officer, Sandwell MBC. 2013.Department for Environment Food and Rural Affairs. Newgovernment buying standards for food and catering.2011. ards-for-food-and-catering/Department of Health. Healthier and more sustainablecatering: toolkit and supporting nutrition principles. g-nutritionprinciplesDepartment of Health. Public health responsiblity deal2013. responsibilitydeal.dh.gov.uk/.Good food for London 2013. www.london.gov.uk/sites/default/files/good food for london report 2013.pdf11
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Obesity and the environment: regulating the growth of fast food outlets 3 1. The importance of action on obesity In 2011 the government published 'Healthy lives, healthy people: a call to action on obesity in England',1 which described the scale of the obesity epidemic and set out plans for action across England.*
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