Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Public Health (DPH)


Community Health and Social Sciences


Terry Huang

Committee Members

May May Leung

Jim Sherry

Subject Categories

Public Health


Obesity, food industry, collective impact, benchmarking, public-private partnership, Delphi study



Despite increased public health efforts and investment in obesity prevention, obesity continues to be a growing problem in the United States.1 Excess weight increases the risk for a series of correlated diseases, such as type 2 diabetes, hyperinsulinemia, hypertension, dyslipidemia, joint abnormalities, polycystic ovarian syndrome, nonalcoholic fatty liver disease, sleep disturbances and a decreased life span.2–9

Traditional interventions to improve nutrition or decrease obesity have not achieved the desired success so far because obesity is a complex problem, involving a vast number of factors, sectors and actors that influence individuals’ energy balance.10,11 To achieve change in a complex system, it is crucial to adopt a collective response that intervenes at different levels and spans multiple sectors.12 Such response would see a coordinated effort between actors from different sectors toward the common goal of reducing obesity. Though still controversial, several authors and international organizations have highlighted the necessity of involving food and beverage companies – with appropriate monitoring and accountability systems – given the crucial role they play in shaping the food production and consumption environment.13–17

Food and beverage companies have already made substantial investments aimed at improving communities’ access to food and encouraging healthful eating and active living. Although the presence of the private sector in the public health space is growing at a rapid pace, there is limited research on its actual impact, and the supposed “added value” of industry-sponsored initiatives is often grounded on anecdotal evidence and best-practice reasoning.18

In response to the growing need for objective assessments of health initiatives funded by the private sector, the Commitment to Healthy Communities (CHC) initiative developed a new methodology to benchmark the strategy and performance of community-based food access, healthful nutrition and active living programs in the US funded by food and beverage companies.

The initiative also included developing and piloting a new tool to assess the collective impact the companies’ strategies have at the community level.

This dissertation sought to analyze the results of the CHC initiative and to use scientific lenses to suggest a roadmap for public-private collaboration in obesity prevention initiatives. The results of the three papers shed light on the impact of current privately funded initiatives in community health and suggest a framework for future multi-sectoral collaboration with a specific focus on portion guidance and management.

Methods for CHC assessment: We developed an industry survey based on best practices in corporate benchmarking while incorporating concepts from the collective impact framework. The survey evaluated four domains of community initiatives: 1) strategy design; 2) governance and management; 3) monitoring and evaluation; and 4) reporting, communication and stakeholder engagement. Eleven companies participated. Quantitative and qualitative data on companies’ obesity prevention and food access initiatives were collected through an online platform and validated by the research team. For each dimension and overall, a percentage score was computed for each company. Domains 1, 2, and 4 above were given a weight of 20% while domain 3 was given a weight of 40% in the final score.

Method for community-based assessment: We developed the Collective Impact Community Assessment Scale, which evaluates programs along 14 dimensions. Five community programs funded by five companies participated in the testing of this tool. Qualitative data were collected through in-person key informant interviews, focus groups, and direct observations of program activities. Eight interviews/focus groups (representing program management, delivery staff, participants and community champions) were selected in each program for review and analysis using a scoring system with pre-established anchors and algorithms to arrive at quantitative metrics of CI. Raw scores ranged on a scale from 0 to 8 for each dimension and were standardized as percentages. Scores for all 14 dimensions were averaged to generate a total composite score.

Methods for Delphi study: The study consisted of an iterative process of administering three rounds of surveys to a panel of experts – representing the fields of obesity, public health, food production, access and distribution, and the broader nutrition field – over a period of three months. The surveys included questions aimed at gathering opinions on the following issues surrounding portion guidance: psychological mindsets that can affect portion size choice, eating habits, portion perception and distortion, passive overconsumption, and challenges and advantages of this tool to improve population nutrition. The surveys also included questions regarding envisioned changes in the food environment in the future. After every round we analyzed all answers and transformed the questions into more narrow agreement queries in order to reach group consensus on specific items in the subsequent round.

Results: Nine companies provided enough quantitative data to be scored in the CHC assessment. Overall scores ranged from 27% to 69% (mean=53%, median=55%). Companies scored between 18-83% on strategy design (mean=60%, median=62%); 26-89% on governance and management (mean=64%, median=65%); 24-60% on monitoring and evaluation (mean=40%, median=37%); and 27-89% on reporting, communication and stakeholder engagement (mean=63%, median=67%). There was a positive, exponential relationship between companies’ overall scores and the level of financial investment in community-based programs.

For the community assessment, total composite scores of CI for programs ranged from 63% to 89%. The CI dimensions that scored the highest were “backbone infrastructure” (median=94%, range=88%-100%) and “common agenda” (median=91%, range=59%-97%). All programs scored lower on dimensions related to their ability to impact funding flows (median=47%, range=34%-94%), cultural norms (median=69%, range=34%-88%), and advocacy and public policy (median=56%, range=25%-69%).

The Delphi study found that, although many experts fear that portion size interventions might be perceived as paternalistic, 91% of respondents agree that these innovations should be stealth and unnoticed. 73% of experts believe that the most impactful portion size information is product reformulation while simply producing smaller packages is the most effective intervention according to only 16% of experts. The majority of the panel (59%) also believes that creating an artificial stopping point in packages is the best strategy to reduce food consumption. Finally, the study found that one of the most complex aspects of establishing a multi-sector collaboration for obesity prevention is to ascertain trust in the private sector’s ability to go beyond the profit versus responsibility conundrum.

Conclusion: The complexity of the obesity issue requires collaboration from different actors across all areas of the complex food environment. The CHC initiative presents an innovative and promising methodology to assess these efforts in a rigorous manner and provide specific feedback on areas that need further improvement. This evaluation framework also provides best practice standards against which different companies can set their goals and objectives. This dissertation has uncovered an area of potential growth that could push companies to maximize their collective impact. Finally, this dissertation has set the stage for future public-private collaboration to improve population nutrition through portion size initiatives. It has identified important points of agreement and obstacles that can inform the agenda of such a movement and shape next-generation obesity prevention programs.

Included in

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