Constructing UK obesity policy: discourse, framing, and politics

Abstract

The global food system, and the production and promotion of less healthy, heavily processed foods pose significant public health challenges. Decades of economic policies that have enabled the concentration of food production and retail among a small number of large, multinational corporations, and the powerful influence of these companies on policymaking, have curbed efforts to introduce effective health policies. Much public health research has focussed on generating evidence to support effective policies that address these failures of our food systems. More recently, increasing recognition of the commercial determinants of health as vectors of disease has expanded the public health field’s focus onto the politics of health policy. It has led also to important inter-disciplinary research between health sciences, politics, and governance studies on the public acceptability and legitimacy of population-level public health policies, including those designed to address less healthy diets and obesity. However, this research has not generally considered how this health condition comes to be considered as a problem, and how the potential solutions, or policy responses, to these problems are discursively constructed and (de)legitimised. It has also generally neglected in-depth consideration of why obesity policy in the UK continues to ascribe to individualised approaches to obesity policy and has not utilised resources from social and political theory to investigate this situation of policy stasis. In this thesis, I sought to address this gap in the literature through a qualitative analysis of academic, media, and policy elites’ discourses on obesity in public health, through the form of UK government obesity strategies. More specifically, I examined the debate over obesity strategies, including the specific case of calorie labelling in the out-of-home sector (CLOOH) in England, in order to gain insight into the discursive environment of this realm of public health policymaking. I did so through three distinct but interlinked components: a literature review (Chapter 3) and two empirical studies, including a framing analysis of media coverage of CLOOH (Chapter 4) and a post-structural discourse theory (PDT) analysis of interviews, policy documents, and consultation responses to CLOOH (Chapter 5). First, I conducted a critical scoping review of academic and grey literatures on the legitimacy of state intervention into dietary practices. I searched 10 databases and 4 journals and screened texts to produce a corpus of 35 articles that addressed this topic. Through critical reflexive thematic analysis, I generated 6 themes and 2 subthemes concerning choice, responsibility for health, balancing benefits and burdens of intervention, the use of evidence, fairness, and the legitimacy of the state’s actions. I found that narratives and logics that work to prevent public health policies pervade academic literature and draw on discourses of individual liberty and personal responsibility to locate the burden of poor health outcomes on the shoulders of individuals, both morally and practically. Utilitarian arguments about financial costs and benefits are the norm for public health policymaking calculus. Claims about fairness, freedom, and evidence were used strategically to support interests, including those of the food industry. These findings serve as a caution against unreflexive engagement with the language and logics of free market economics by public health advocates, researchers, and policymakers. A more reflexive form of engagement could entail challenging the norm of relating the impact of public health policy in financialised terms of ‘costs’ and ‘benefits’ and instead formulating alternative framings that articulate public health in terms of social or community benefits (e.g., solidarity, wellbeing). This study represents my attempt to capture engagement with my object of study – how arguments about the justifiability of obesity policy play out across disciplines – using an adaptation of the traditional public health method of the systematic-style review. This experience leads me to engage with the limits of what it is possible to do and know through this approach – namely, that it lacks the power to explain the intractability of this issue in public discourse and fails to engage with discourse beyond the level of narrative or argument. In an effort to address this limitation, in my second study, I turned to another way that communication about public health policy has been investigated: framing theory. I performed a qualitative framing analysis of media coverage of CLOOH introduced as part of the Tackling Obesity government strategy. Though this strategy initially included instruments to address structural determinants of health, including the physical and digital food environment, it ultimately failed to shift responsibility for ill health onto structural actors, including industry. Most obviously, CLOOH, one of the strategy’s only two implemented measures, was predominantly framed as modifying the food environment to improve informed choice and individual decision-making, with a secondary goal of encouraging product reformulation. This study used the contestation of CLOOH in English newspapers to investigate the role of media framing in facilitating lifestyle drift, which describes the tendency for policies ostensibly designed to address structural determinants of health, including the physical environment, to regress back to individualism. I identified framing of policy problems, the solutions meant to address them, and the actors involved in the policy process from 177 media articles published between January 2017 and May 2022. I found that media framing foregrounded individualism, personal responsibility, and moralisation of behaviour. It also emphasised the perceived ineffectiveness, unfairness, and unintended consequences of calorie labelling, including negative impacts on the economy and people living with eating disorders. Despite an initial shift towards framing interventions to address obesity through a structural lens in Tackling Obesity, the implemented form of CLOOH and accompanying news coverage reflect a drift back towards individualism. Through this framing analysis, I sought to address the problem at the heart of my thesis through a different avenue: framing theory conceptualises public discourse as a process of creating, transmitting, and receiving information in the form of frames that draw on deeply held common meanings and values. This approach describes the intractability of this policy debate, but I found that it was not able to explain why this is, and how this situation came to be – for example, from where free market frames come, or why they persist despite resistance expressed from the public health community. To address this explanatory gap, I turned next to PDT and the critical logics approach (CLA). In my third study, I critically analysed responses to a public consultation on CLOOH (n=88) alongside public documents (n=15) and transcripts from interviews that I conducted with policy elites (n=15). I employed a critical logics approach to discourse analysis drawn from the field of post-structural discourse theory. I argued that the content of the debate about CLOOH (as social logics) can be understood through analysis of the formation and dissolution of political frontiers (political logics) and the affective ‘grip’ that narratives exert over actors, institutions, and social normativity (fantasmatic logics). Intervention-favourable and resistant discourses alike are structured by similar logics and cannot be understood as directly oppositional. Rather, these discourses are similarly committed to neoliberal hegemonic principles and characterised by shifting political coalitions that cannot be divided simply by political party or sectoral lines. My analysis also draws attention to the role of (de)politicisation, metaphor, and populism in contemporary UK obesity policy discourse as well as the under-explored role of emotion and fantasy in contributing to political ideologies about health and obesity. I found that the CLA, in its use of logics and in particular, political and fantasmatic logics, was able to provide a more detailed explanation that moved beyond a process-oriented narration of what happens in policy discourse to uncover the underlying logics and fantasies that motivate social practices. Connecting social and political practices to hegemonic policy regimes and ideological practices supported by logics supplements existing critiques of corporate political activity and power to the underlying ‘rules of the game’ that govern policy domains, including public health. In bringing together these three studies, I analysed diverse sources of qualitative evidence and used interdisciplinary methods to highlight how obesity policymaking is inevitably political, and how the choice of language and framing can contribute to the maintenance of harmful policy paradigms. In doing so, I adopt the position of the interpretive bricoleur, reflexively moving between qualitative methodologies in my researcher’s toolbox to foster an interdisciplinary conversation between qualitative approaches. I found that the preponderance of neoliberal ideologies in public health discourse; the consequences of the unproblematised use of a medical and embodied framing of obesity; the rhetorical use of the public and its opinions to legitimate policy positions, including strategic reference to underserved and socially disadvantaged groups by business actors and their allies; and patterns of contradictions, which signal the operation of ideological practices serve as barriers to effective obesity strategies and reinforce the status quo. Future research should further investigate alternative discourses that challenge the neoliberal public health paradigm, and particularly consider the experiences of non-Western contexts with histories of public health success, such as Chile and Brazil. It should also investigate how the discursive framing of public opinion and acceptability compares to the expressed opinions of the public to further unpick how discourses are received and acted upon by individual citizens. The use of PDT and the CLA should be extended to other studies of the CDOH to equip researchers with the methodological, ontological, and epistemological tools to make sense of affect and emotion in policy discourse. Finally, I recommend that public health consider adopting the (left) populist tactic of e.g., global food sovereignty movements to counter neoliberal and corporate populist strategies.