Series: Volume 4, Issue 2 2014

Introduction

In early 2013, Ban Ki-Moon, Margaret Chan and Kofi Annan had something in common: they may be completely unaware of it, but I saw them speaking in Geneva, and not merely because I lurked around Palais de Nations. Rather, wielding my very own blue United Nations (UN) ID card as an intern at the World Health Organization headquarters (WHO), I became a de facto insider to events on the international stage.

Between January and March, I undertook an 11 week internship with the WHO Emergency and Essential Surgical Care (EESC) Program in the Clinical Procedures Unit, Department Health Systems Policies and Workforce. The WHO is the directing and coordinating authority for health within the UN. It is responsible for providing leadership on global health issues, setting the research agenda, setting and articulating norms, standards and evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends. [1] At some point during your studies, you will encounter material developed and disseminated by the WHO. You may have cited WHO policies in your assignments, looked up country statistics from the Global Health Observatory before your elective, or at least seen the ubiquitous Five Moments for Hand Hygiene posters, which emerged from WHO guidelines. [2] In other words, if you haven’t heard of the WHO or don’t recognize the logo, then I suggest taking a break from textbooks and click around the many fascinating corners of their website. Perhaps watch Contagion for a highly stylized (but filmed partially on location) view of an aspect of their work. [3]

The WHO and Surgery

The WHO established the EESC Program in 2005, in response to growing recognition of the unaddressed burden of mortality and morbidity caused by treatable surgical conditions. [4] This reflects the lack of prioritization of surgical care systems in national health plans and the ongoing public health misconception that surgical care is not cost-effective and impacts only upon a minority of the population. [5] These misconceptions apply as much to those in the field of public health, as well as to surgeons on the ground and in the literature, let alone those at other agencies. This was reflected by the question I all too commonly faced when explaining my internship: “The WHO is involved in surgery?”

In reality, surgical conditions contribute to an estimated 11% of the global burden of disease. It is a field that cuts across a number of public health priorities. [6] For example, progress on many of the Millennium Development Goals demands the prioritization of surgical care systems, most obviously in connection with maternal and newborn care. [7] Timely access to surgical interventions, including resuscitation, pain management and caesarean section, are vital to reducing maternal mortality. [8] Even in its most basic forms, surgical procedures can play a role in both preventative and curative therapies, from male circumcision in relation to HIV control to the aseptic suturing of wounds. However, surgery also has a very real impact on poverty by addressing the underlying causes of disability which often contribute to unemployment and debt.  These include the management of congenital and injury incurred disabilities and preventable blindness. [9] Surgery can be a complex intervention because it relies upon numerous elements of the health system to be functioning completely. There is little point in having access to basic infrastructural amenities like electricity, running water and oxygen, when at the moment of an emergency it is unavailable. Similarly, having equipment and supplies alone are insufficient when there is a shortage of a skilled workforce to wield them.

The WHO EESC is dedicated to supporting life-saving surgical care systems in the areas of greatest need, through collaborations between the WHO, Ministries of Health and other agencies. The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) is an online network linking academics, policy makers, health care providers and advocates across 100 countries. Together, they developed the WHO Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit to equip health and government workforces with WHO recommendations, skills and resources, focusing on emergency, trauma, obstetrics and anaesthesia, in order to improve the quality of, and access to, surgical services. [4]

In terms of my role, let me begin with the caveat that, as an intern, one can be called upon to conduct a wide variety of tasks within the huge scope of the WHO. My experiences differed greatly from those of colleagues and are not necessarily reflective of what one may encounter in other departments, or even in the same program at different times of year. I applied through the online internship application, but amongst my colleagues, this was in fact a rarity. [10] By far the majority of interns had applied directly or through their university to the specific areas of the WHO that aligned with their interests.

I undertook both administrative and research tasks, working very closely with my supervisor, Dr. Meena Cherian. There is a paucity of evidence capturing the surgical capacity, including infrastructure, equipment, health workforce and surgical procedures provided, across facilities in low- and middle-income countries. Through the GIEESC network, the WHO Situation Analysis Tool captures the capacity of first-referral health facilities to provide emergency and essential surgical care. [4] One of my key roles was in data collation and analysis. In terms of tangible outcomes, in the span of my internship I was able to contribute to two research papers for submission. In terms of my education, however, it was the administrative roles that demonstrated many of the key lessons about working in international organizations, and for which I am most grateful. Although menial tasks like photocopying and editing PowerPoint presentations can seem futile, carrying those documents into meetings allows one to witness the behind-the-scenes exchanges that drive many international organizations. This deepened my understanding of the WHO’s functions, strengths and limitations. In my experience, exacerbated by funding limitations and the rise of game-changing new players from the non-government sector, such as the Bill and Melinda Gates Foundation, attracting and justifying resource allocation to marginalized areas like surgery becomes a full-time job in itself. Opportunities for collaboration with such NGOs can result in successful innovation and programming, as with the polio eradication campaign. However, although inter-sector and inter-department collaboration is seemingly an obvious win-win, the undercurrents of turf wars and politicization of health issues can make such collaborations seem like a delicate diplomatic performance. Effective WHO engagement with external stakeholders cannot come at the cost of its intergovernmental nature or independence from those with vested interests. [1] Such are the limitations imposed on international organizations by the international community and the complex relationships between member states.

Ultimately, learning to collaborate with colleagues across cultural, economic, resource and contextual barriers under the tutelage of my supervisor has implications for any future endeavor in our increasingly globalized workplaces.  Learning to navigate such competing social and political interests is as applicable to clinical practice as it is to public health. Furthermore, the Experts for Interns program initiated by the WHO Intern Board provides bi-weekly lunchtime seminars specifically designed to broaden the scope of the intern experience by facilitating discussion with experts in various fields. [11] These were particularly valuable as an opportunity to ask direct questions, challenge preconceived notions and reexamine the historical development of public health, global health and the role and scope of the WHO.

Personal Highlights and Challenges

Geneva is an international city, home not only to WHO HQ and the United Nations in Europe, but also to a number of other UN Agencies and international non-governmental organisations, including Médecins Sans Frontières and the International Committee of the Red Cross. This means that, at any given time, there are a huge number of international and cultural events occurring. During my stay alone, there was the WHO Executive Board Meeting, the Geneva Human Rights Film Festival, a number of conferences, the UN Human Rights Council and some truly high profile speakers. Hans Rosling, the rock star of epidemiology and a founder of GapMinder, has put together a great TED Talk, but seeing him speak in person was one of my most lively, educative and stimulating experiences. [12,13] It is a memory I will treasure and return to for motivation, particularly when rote learning another fact for an  exam seems impossible. For many of us who aspire towards a career in global health, seeing these famous faces and learning firsthand about their work and career pathways is more than just inspiring, it can become a raison d’être.

From a slightly more cavalier perspective, Switzerland is centrally located in Europe, and Geneva as an international city is a great base from which to travel. It is easy to find sale flights to major European destinations, and the train to Paris takes only three hours. As an unpaid intern, your weekends are your own and most supervisors are generous about allowing travel grace. The opportunity to explore a new city every weekend is alluring, and with options like the demi-tariff, the half-priced fares on Swiss trains, it’s certainly a possibility. The Geneva and Lac Leman region features charming villages and cities with the sort of breathtaking mountain views that makes everything look like a postcard, not least if it’s covered in a blanket of pristine white snow. This is the other key attraction of Geneva in winter: if you’re into snow sports, you will be based within an easy day trip to some of the best pistes in the world. Indeed, the Swiss penchant for such trips seems to be why Sundays find Geneva a ghost town of sorts. Aside from the odd museum, absolutely nothing is open on Sundays, to the point where if you make my mistake of arriving on Sunday, it may be difficult to even find food.

Even if you can find food on a Sunday, affording it and anything else in Geneva is not easy. The cost of living is high, and, despite the high turnover of ex-pat staff, finding a place to stay is extremely difficult. As Australians we have it luckier than most, by being able to make use of OS-HELP loans while studying overseas. There is an ongoing discussion about paid internships within the UN, and there are varying practices amongst agencies. Some, notably the International Labor Organization, pay interns, while the WHO and others do not. This has become an advocacy issue amongst interns, as it severely limits access to the educative and career-oriented experiences internships provide for those from middle- and low-income nations. However, it seems unlikely that this will change in the near future. Nonetheless, with careful saving, planning and some basic austerity measures, finances should not deter you from this experience.

Another potential challenge is that Geneva is in francophone Switzerland; it is geographically surrounded on most sides by France. Many WHO staff and interns live, or at least shop, across the French border, where I discovered amazing supermarkets with entire aisles devoted to Swiss and French cheeses and chocolate. As a hopeless Francophile, this was a delicious highlight. I took classes and developed my French while safely working in a predominantly anglophone environment. If you have never studied French, then learning basics pre-arrival would be recommended, though it is possible to get around Geneva without, as the locals are very generous in this regard. However, there were often times when my linguistic limitations perpetuated anglophone dominance, forcing colleagues to transition into my language of choice. Such language barriers can also contribute to cultural misunderstandings.  For example, early on I committed the fauxpas of being too casual in the more hierarchical workplace, where professional titles were used even in personal conversations. Coming from the more egalitarian Australian context, this can come as something of a culture shock, though it varies considerably between different offices and departments.

As a result of my experiences, I am now both more cynical and more hopeful about the future of global health. The bureaucratic limitations of the WHO are also where its authority lies. Sifting through convoluted Executive Board meetings, it is easy to become skeptical about the relevance of this 65-year old organization. However, this belies the power of health mandates supported by member state consensus, whether in regards to the Tobacco Free Initiative or the Millennium Development Goals. Such change and reform, though slow, is broad reaching and invigorating.

Finally, the most significant and meaningful experiences I shared during my internship were not with the famous faces of global health, but with my peers. Across the various organizations based in Geneva, there are a huge number of interns from all over the world. Making connections with these kindred spirits, who shared my interests and a similar desire for an international career, was such a privilege. Even when our areas of interest did not intersect, it was amazing to learn from the expertise of fellow interns and students. For example, a fascinating experience was encountering a student at CERN (Conseil Européen pour la Recherche Nucléaire, better known to us non-physicists as the home of the Large Hadron Collider) with whom I was able to have a sticky beak at the labs and lifestyles of modern physics’ greatest thinkers. Just as he is progressing towards becoming a don of theoretical physics, at some point in the next few decades many of the friends I’ve made through this internship are going to become the next generation of global health leaders. More importantly, creating such networks across continents and across specializations has been instrumental in shaping my sense of self and perspective, and has left an indelible mark in the form of new education, career and lifestyle aspirations.

Where to from here for you

There is an online intern application through the WHO website. Although I completed this as my elective term, I also encountered a number of students from Australia for whom this was a summer opportunity to experience the organization, or as part of their research. I would strongly urge any student with interests in public health, global health, policy or research to consider applying for this opportunity, and to do so by contacting the departments of your interests directly.

In terms of surgery and global health, please visit the EESC program website at www.who.int/surgery for further information, and to become a GIEESC member.

Acknowledgements

The author wishes to acknowledge the generosity of the WHO Clinical Procedures Unit, particularly Dr. Meena Cherian of the WHO Emergency and Essential Surgical Care Program, who hosted her internship, and the financial support of the Australian government OS-HELP loan program.

Conflict of interest

None declared.

Correspondence

L Hashimoto-Govindasamy: laksmisg@gmail.com

References

[1] World Health Organization. About the WHO. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.who.int/about/en/

[2] World Health Organization. Clean care is safer care: five moments in hand hygiene. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.who.int/gpsc/tools/Five_moments/en/

[3] International Movie Database. Contagion. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.imdb.com/title/tt1598778/

[4] World Health Organization. Emergency and essential surgical care. [Internet]. 2013 [cited 2013 March 26]/ Available from: http://www.who.int/surgery/en/

[5] Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372:139–44.

[6] Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison D, editor. Disease Control Priorities in Developing Countries. 2nd ed. New York. Oxford University Press; 2006.

[7] United Nations. Millennium Development Goals. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.un.org/millenniumgoals/

[8] Kushner A, Cherian M, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg. 2010;145(2):154-160.

[9] PLOS Medicine Editors. A crucial role for surgery in reaching the UN Millennium Development Goals. PLOS Med. 2008;5(8):e182.doi:10.1371/journal.pmed.0050182

[10] World Health Organization. WHO employment: WHO internships. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.who.int/employment/internship/interns/en/index1.html

[11] WHO Interns. Experts for interns (E-4-I). [Internet]. 2013 [cited 2013 March 26]. Available from: http://whointerns.weebly.com/experts-for-interns.html

[12] TED: Ideas worth spreading. Hans Rosling: Stats that reshape your worldview. [Internet]. 2006 [cited 2013 March 26]. Available from: http://www.ted.com/talks/hans_rosling_shows_the_best_stats_you_ve_ever_seen.html

[13] Gapminder. Gapminder: for a fact-based worldview. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.gapminder.org/

Whilst a number of factors contribute to Australia’s rapidly rising obesity rates, the role of fast food companies in addressing the epidemic remains controversial. This report discusses the contribution of fast food companies to high obesity rates, explores the notion of corporate social responsibility, and discusses a range of government policies that could be implemented to limit the contribution of fast food chains in promoting obesity.

Introduction

Obesity is a major concern in Australia, with 62.8% of the adult population termed overweight (35.3%) or obese (27.5%). [1] Multiple factors contribute to these rising statistics, and whilst fast food companies undeniably contribute to obesity, defining the exact role that they play and their responsibility remains controversial. Whilst difficult to numerically define, previous studies have offered various definitions of fast food, broadly defining it as food purchased from cafeterias, restaurants and ‘big brand’ companies (such as McDonalds) that are high-calorie and low in nutritional value. [2-4] Food produced in restaurants, for example, is at least 20% higher in fat-content than the home-cooked equivalent. [5] It has now been over a decade since the infamously termed ‘McLawsuit,’ in which a group of overweight children in America filed legal action against the McDonalds corporation for their obesity-related health problems, first bringing the issue of corporate responsibility to a head. [6] Increasingly, now, trends are towards increasing regulation of the fast food industry, with recent debate over a fat tax in Australia, [7] and New South Wales enforcing nutrition labelling of fast food products. [8] The obesity epidemic continues to contribute to the morbidity and health expenditure of many developed countries, with minimal resolution on the role that fast food companies should play in tackling it.

Obesity in Australia: The contribution of fast food companies

The complex array of factors contributing to obesity makes the issue of responsibility a difficult one. [9] Australia’s obesogenic environment comprises multiple factors, such as increasingly sedentary lifestyles, poor education regarding nutrition and the accessibility of fast food. [10] In this respect, fast food companies, government and the wider community are all stakeholders with differing degrees of responsibility.

Fast food companies are considered a key stakeholder in contributing to Australia’s obesogenic environment. This is attributed to factors such as their large portion sizes, and marketing ploys that intensively promote the accessibility of unhealthy snack foods and target vulnerable groups such as low-income earners and children. [11] These factors make it difficult for consumers to make informed choices and resist unhealthy options, ultimately contributing to overeating and excess body weight. [12] Establishing a causal link between fast food companies and obesity is difficult due to the complexity of the relationship. An analysis by Chou, Rashad and Grossman (2005) indicated that a ban on fast food advertising would reduce the number of overweight children by 10% in the 3-11 year age group, and by 12% amongst 12-18 year olds, suggesting a causal component to the relationship in this vulnerable population group. [13] Accessibility of fast food outlets is also a contributing factor, with Maddock and colleagues (2004) showing that there is a significant correlation between proximity to fast food restaurants and obesity. [14] Furthermore, ever-increasing portion sizes also provide evidence for the influence of fast food companies on obesity; with Young and Nestle (2002) noting that portion sizes have paralleled the increase in average body weight. [15] Whilst some claim that fast food companies simply respond to consumer desires, and that the average consumer is well aware of the obesity epidemic, it can be argued that they are still partly responsible by providing and promoting this supply.

Corporate Social Responsibility

Corporate Social Responsibility (CSR) is a form of self-regulation that corporations integrate into their business model. [16] It involves taking responsibility for the impact of the company’s decisions on society and the environment. [17] Guler and Crowther (2010) further describe CSR as honouring the triple bottom line of people, planet and profit rather than solely focusing on profit maximisation. [18]

Proponents of CSR claim that it maximises long-term profits by encouraging firms to operate sustainably, decreasing risks despite initial costs. [19] Wood (2010) argues that ‘strategic CSR’ rewards business for CSR activities via the positive responses of consumers, employees and shareholders. [20] Ethical business policy may lead to brand differentiation and customer loyalty, increasing purchase intention and willingness to pay. Similarly, employees may be attracted and motivated by strong CSR policies, potentially increasing recruitment, work ethic and employee loyalty. Successful CSR strategies can also improve a firm’s reputation, reduce external pressure from non-government organisations (NGOs) and attract shareholders. [21] For example, Becker-Olsen et al. (2006) argues that McDonald’s funding of programs such as Maths Online, Little Athletics and its Ronald McDonald House Charities acts as subconscious advertising to improve its reputation. [21-23]

However, as well as these incentives, firms also face challenges in establishing CSR policies. Some economists claim that CSR distracts from the role of business, which is to maximise profit. [24] The financial costs of introducing CSR policies may also be barriers for firms, particularly small businesses that lack the required resources. [20] Moreover, CSR does not necessarily equate to positive consumer perceptions, as the credibility of corporations is often doubted. [21] For example, partnerships between KFC and the McGraw foundation, McDonalds and WeightWatchers, and Nestle and Jenny Craig have been criticised as marketing ploys, termed ‘weightwashing’ by the Obesity Policy Coalition. [25]

In the context of Australia’s obesity epidemic, CSR policies in the food industry may have varied impacts. Fast food companies, at a time of increasing obesity rates, may see an opportunity in utilising health policy to establish consumer goodwill and brand value, creating a profit-driven incentive to engage in obesity prevention. Self-motivation in CSR policy construction could, however, be detrimental to health prevention, with, for example, fast food companies shifting blame from ‘foods’ to ‘sedentarism’ in their marketing, rather than altering the quality of their products. [20] Additionally, as a defensive response to avoid government regulation, the food industry has created an opening for itself in a health and sports promotion role, which, whilst contributing to preventative health programs in the short-term, may in time detract from the conventional governmental role in public health, devolving government of some responsibility without effectively satisfying community needs.

Despite its challenges, the potential benefits of CSR and the rise of privatisation and globalisation make self-regulation in the food industry an important, and perhaps inevitable, approach to consider in tackling obesity. [25]

Government Regulation

In light of steadily increasing obesity rates in many Western societies, a number of governments have implemented policies to reduce the impact of fast food companies in promoting overeating. [26,27] Outlined below are four categories of legislative change and their implications.

Restricting fast food advertising

Fast food advertising can send misleading messages to consumers, particularly those less informed. [28] Ethically, from a communitarian perspective, restricting advertising may denormalise fast food by making it less ubiquitous, helping change social attitudes, which is key to combating obesity. [29] Conversely, restrictions on advertising limit choice by making consumers less aware of their options, contradicting the principle of autonomy. Whilst it could be said that advertising of healthy foods continues to provide this autonomy, critics argue that fast food is not harmful in moderation and thus consumers should be able to make an informed decision of their purchases. Similarly, in alignment with narrative ethics, individuals have different approaches to eating, which may be compromised by eliminating the information delivered by fast food advertising. [30,31] It is important to note, however, that many of these concerns assume advertising delivers accurate information, which is often not the case. Critics also claim that restricting advertising is ineffective, as there are more important factors contributing to obesity. In addition, there are concerns about how the distinction between healthy and unhealthy foods would be made and the rights of companies to market their goods. [32]

Examples of restrictions on fast food advertising include banning fast food company sponsorship of sporting events and celebrity endorsement of unhealthy foods, as well as banning advertising that targets children, a population group particularly susceptible to marketing ploys. In regards to this, banning advertising to children in prime-time hours has already been successfully achieved in a number of countries. Quebec, for example, has had a 32-year ban on fast food advertising to children, leading to an estimated US$88 million reduction in fast food expenditure. [33] Australia has been moving towards restricting fast food advertising that targets children, with the Australian Food and Grocery Council resolving to not advertise fast foods in programs where at least 35% of the audience are children. [34] However, analyses of the difficulties of self-regulation in the food industry indicate that its effectiveness depends on the rate of engagement by individual companies and is not sufficient to adequately protect consumers. [35,36]

Cost measures

A ‘fat tax’ would involve taxing foods or beverages high in fat content (other ‘unhealthy’ components such as sugar and salt could also be taxed). It aims to discourage consumers from unhealthy products and offset their health costs with the tax revenue generated. [37] Subsidies for healthy food options are considered less practical with a greater cost-burden for taxpayers. Critics argue that a ‘fat tax’ would disproportionately affect low socio-economic consumers, unless healthy alternatives are made cheaper. [38] Some argue that obese individuals are also less responsive to increased prices than consumers of average BMI, reducing the effectiveness of a tax. [39] A ‘fat tax’ could even exacerbate health problems – a tax only on saturated fat, for example, may increase salt intake, which increases cardiovascular risk. [38] Denmark was the first country to introduce a tax on fat in 2011; however, it has since resolved to repeal the legislation, claiming that it increased consumer prices, increased corporate administration costs, and damaged Danish employment prospects without changing Danish eating habits, reducing the likelihood of this approach being trialled by other countries, including Australia. [40] It should be noted, however, that country-specific differences may have contributed to its lack of success.  These include the ability of the Danish population to travel to neighbouring countries to maintain their eating habits despite the government tax, which would not be feasible in Australia. Alternatively, the government could consider combining subsidies for healthy food options with a ‘fat tax,’ as this approach would be more acceptable to the public than a tax alone, and also yield a lower cost-burden for taxpayers than subsidies alone.

Nutrition labelling

Nutrition labelling aims to ensure consumers understand the nutritious value of foods. In Australia, all food labels must abide by the national Food Standards Code. [41] Options to simplify food labelling include traffic light food labelling, which codes foods red, yellow or green based on their fat, sugar and salt content. [42] Another option is health warnings on unhealthy foods to deter consumption. [43] Australia-wide, a new star rating system for packaged foods has been developed by a working group which included industry and public health experts; as of June 2013, this has been approved by state and federal governments. [44] The scale will rate foods from half-star to five stars based on nutritional value, despite concerns raised by the Australian Food and Grocery Council over the cost to manufacturers and how nutritional value would be determined. Sacks et al. (2009) argues, however, that there is insufficient evidence to suggest that food labelling would reduce obesity. [45] Critics also argue that more restrictive practices, such as health warnings, are excessive and impractical considering the ubiquity of high fat foods. [46]

Limit physical accessibility of fast food

Easy accessibility of unhealthy foods makes them difficult to resist. Making fast food less accessible again denormalises it, helping change social attitudes. This is supported by studies showing that obesity rates are higher in areas with an increased number of fast food outlets. [14] Zoning laws have been suggested as a policy tool to limit the accessibility of fast food, with findings suggesting success in reducing alcohol-related problems. [47] Other approaches to restrict access include removing fast food from high accessibility shelves in supermarkets, banning fast food vending machines and banning fast food from school canteens. Victoria, for example, has imposed strict canteen rules restricting the sale of fast food to twice a term. [48] However, critics argue that restricting the accessibility of fast food may undermine consumer autonomy and choice, impinge on the legal rights of companies to market their goods, and could also be a precedent for government intervention in other areas. [49]

Conclusion

Whilst it is difficult to define the extent of the role that fast food companies play, there is no doubt that they significantly contribute to Australia’s obesity epidemic through their large portion sizes, low quality food, extensive fast food advertising and high accessibility. Ultimately, combating obesity will require a multi-faceted approach that denormalises unhealthy foods – a process that requires both consumers and government to take a role in regulating the quality, marketing practices and accessibility of unhealthy products produced by the food industry.

Conflict of interest

None declared.

Correspondence

S Bobba: samantha.bobba@gmail.com

References

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[3] Pereira, M, Karashov, A, Ebbeling, C, Van Horn, L, Slattery, M, Jacobs, D, Ludwig, D. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005; 365(9453):36-42.

[4] Duffy, B, Smith, K, Terhanian, G, Bremer, J. Comparing data from online and face-to-face surveys. Int J Market Res. 2005; 47(6):615-639.

[5] Seiders, K, Petty, RD. Obesity and the role of food marketing: a policy analysis of issues and remedies. JSTOR. 2004; 23(2):153-169.

[6] Mello, MM, Rimm, ER, Studdert, DM. The McLawsuit: The fast-food industry and legal accountability for obesity. Health Aff. 2003; 22(6):207-216.

[7] Lewis, S. Federal government backed study into fat tax on fast foods. News.com [Internet]. May 20 2013. [Cited 2013 Apr 15]; Available from: http://www.news.com.au/lifestyle/food/federal-government-backed-study-into-fat-tax-on-fast-foods/story-fneuz8wn-1226646283704

[8] Thompson, J. Forcing fast food chains to join the fight against obesity. ABC News [Internet]. November 8 2010. [Cited 20/4/2013]; Available from: http://www.abc.net.au/news/2010-11-08/forcing-fast-food-chains-to-join-the-fight-against/2328572

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[10] Germov, J, Williams, L. A Sociology of food & nutrition: The social appetite. Melbourne: Oxford University Press; 2004.

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[12] Young, LR, Nestle, M. Portion sizes and obesity: Responses of fast-food companies. .J Public Health Policy. 2007; 28(2):238-248.

[13] National Bureau of Economic Research. Fast-food restaurant advertising and its influence on childhood obesity. Cambridge: NBER, 2005. [Cited 2013 Apr 55/4/2013]. Available from: http://www.nber.org/papers/w11879

[14] Maddock, J. The relationship between obesity and the prevalence of fast food restaurants: state-level analysis. Am J Health Promot. 2004; 19(2):137-143.

[15] Young, LR, Nestle, M. The contribution of expanding portion sizes to the US obesity epidemic. Am J Public Health. 2002; 92(2):246-249.

[16] McBarnet, DJ, Voiculescu, A, Campbell, T. The new corporate accountability: corporate social responsibility and the law. Cambridge: Cambridge University Press; 2007.

[17] Maloni, MJ, Brown, ME. Corporate social responsibility in the supply chain: An application in the food industry. J Bus Ethics. 2007; 68(1):35-52.

[18] Guler, A, Crowther, D. A handbook of corporate governance and social responsibility. Fanham: Gower; 2010.

[19] Porter, ME, Kramer, MR. Strategy and society: the link between competitive advantage and corporate social responsibility. Harv Bus Rev. 2006; 84(12):78-92.

[20] Wood, DJ. Measuring corporate social performance: A review. Int J Manag Rev. 2010; 12(1):50-84.

[21] Becker-Olsen, KL, Cudmore, AB, Hill, RP. The impact of perceived corporate social responsibility on consumer behaviour. J Bus Research. 2006; 59(1):46-63.

[22] McDonalds. McDonalds Corporation: Worldwide social corporate responsibility. 2009. [Cited 2013 Apr 16]. Available from: http://www.aboutmcdonalds.com/etc/medialib/csr/docs.Par.32488.File.dat/mcd063_2010%20PDFreport_v9.pdf

[23] Royle, T. Realism or idealism? Corporate social responsibility and the employee stakeholder in the global fast-food industry. Business Ethics: A European Review. 2005; 14(1):42-55.

[24] Peattie, K. Corporate social responsibility and the food industry. AIFST. 2006; 20(2):46-48.

[25] Martin, J. Rich pickings, fat or thin. Sydney Morning Herald [Internet]. 2010. [Cited 2013 Apr 27]; Available from: http://www.smh.com.au/lifestyle/wellbeing/rich-pickings-fat-or-thin-20110115-19rvj.html

[26] Mitchell, C, Cowburn, G, Foster, C. Assessing the options for local government to use legal approaches to combat obesity in the UK: Putting theory into practice. Obes Rev. 2011; 12(8):660-667.

[27] Diller, PA, Graff, S. Regulating food retail for obesity prevention: How far can cities go? J Law, Med Ethics. 2011; 39(1):89-93.

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