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Introduction1

If you bring the appropriate people together in constructive ways with credible information, they will create authentic visions and strategies for addressing the shared concerns of the organization or community.

The Collaborative Premise (Chrislip and Larson, 1994)

The collaborative premise … is a wonderful statement. But it falls short of what’s really necessary, and that’s action.

—Michael McGinnis, Institute of Medicine, November 2, 2011

From rising obesity rates2 to the fast-growing population of older adults,3 the complex public health challenges of today call for novel approaches and new structures, including collaborative partnerships between the public and private sectors. The Institute of Medicine’s (IOM’s) Food Forum held a workshop on November 1-2, 2011, in Washington, DC, to better understand how to build multisectoral food and nutrition partnerships that achieve meaningful public health results.4

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1 This chapter is based partly on information presented by Cheryl Toner, Sylvia Rowe, and Eric Hentges.

2 More than one-third of the U.S. adult population is considered obese, a figure that has more than doubled since the mid-1970s; among children, obesity rates have more than tripled over the same period (Flegal et al., 2010; NCHS, 2011).

3 The growth rate of the U.S. population age 65 years and older is expected to double over the next 20 years, placing new demands on the food supply and creating new challenges to providing healthy and safe foods to aging populations (IOM, 2010b).

4 This workshop was organized by an independent planning committee whose role was limited to designing the workshop program and identifying goals, topics, and speakers. This workshop summary has been prepared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Food Forum or the National Academies; they should not be construed as reflecting any group consensus.



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1 Introduction1 If you bring the appropriate people together in constructive ways with credible information, they will create authentic visions and strategies for addressing the shared concerns of the organization or community. —The Collaborative Premise (Chrislip and Larson, 1994) The collaborative premise . . . is a wonderful statement. But it falls short of what’s really necessary, and that’s action. —Michael McGinnis, Institute of Medicine, November 2, 2011 F rom rising obesity rates2 to the fast-growing population of older adults,3 the complex public health challenges of today call for novel approaches and new structures, including collaborative partnerships between the public and private sectors. The Institute of Medicine’s (IOM’s) Food Forum held a workshop on November 1-2, 2011, in Washington, DC, to better understand how to build multisectoral food and nutrition partner- ships that achieve meaningful public health results.4 1 This chapter is based partly on information presented by Cheryl Toner, Sylvia Rowe, and Eric Hentges. 2 More than one-third of the U.S. adult population is considered obese, a figure that has more than doubled since the mid-1970s; among children, obesity rates have more than tripled over the same period (Flegal et al., 2010; NCHS, 2011). 3 The growth rate of the U.S. population age 65 years and older is expected to double over the next 20 years, placing new demands on the food supply and creating new challenges to providing healthy and safe foods to aging populations (IOM, 2010b). 4 This workshop was organized by an independent planning committee whose role was limited to designing the workshop program and identifying goals, topics, and speakers. This workshop summary has been prepared by the rapporteurs as a factual summary of the pre- sentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not neces- sarily endorsed or verified by the Food Forum or the National Academies; they should not be construed as reflecting any group consensus. 1

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2 PUBLIC–PRIVATE PARTNERSHIPS IN FOOD AND NUTRITION The purpose of the workshop was • to allow participants representing the private sector, academia, government, and public-interest nongovernmental organizations (NGOs) to openly explore the merits of public–private partnerships in promoting public health; • to foster communication and cooperation between participants from different sectors around the fundamental characteristics and consid- erations that help build healthy, sustainable partnerships; and • to engender dialogue on opportunities of mutual interest in the food arena, such as research, that are most conducive for partnerships. The goals of the meeting were to develop an understanding of • the paradigms and goals from which each sector operates; • the range of collaborative relationships possible, how constructive interactions can be developed, and how communication and dia- logue on partnership formation can be initiated in a way that builds trust; and • the process and actions necessary to facilitate partnership development. As Michael McGinnis, senior scholar and director of the IOM’s Round- table on Value & Science-Driven Health Care, observed in his concluding remarks and as demonstrated in this summary, the workshop achieved its stated goals. Through extensive discussion of the risks and benefits of public–private collaboration and the identification of best practices and models for constructive partnering, including how to manage some of the key ethical challenges of public–private interaction, many workshop par- ticipants identified not only common ground for moving forward but also direction for action. The workshop built upon and complemented several other recent workshops. For example, the National Cancer Institute (NCI) of the Na- tional Institutes of Health (NIH) and the Research, Education, and Eco- nomics (REE) mission area of the U.S. Department of Agriculture (USDA) co-hosted a meeting on September 30, 2011, with the goal of starting a conversation among government, academic, and industry scientists on gaps in food and nutrition knowledge and identifying research areas of mutual interest. According to Cheryl Toner, fellow to the Nutritional Science Re- search Group at NCI, the conversation focused on two key questions. First, what broad areas of nutrition research that are of mutual interest to the food industry, government, and academia have the greatest potential for a positive impact on public health in the medium to long term? Second, what

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3 INTRODUCTION are the existing and potential mechanisms for public–private collaboration in these research areas? Participating scientists identified four research areas with significant gaps in knowledge: (1) the microbiome; (2) biomarkers (in all forms); (3) food composition and dietary intake surveillance data; and (4) consumer behavior. Most of the dialogue focused on the process of generating knowledge (e.g., how to design a research study). There was very little discussion around particular disease conditions, except obesity. With respect to mechanisms for collaboration, Toner remarked that the workshop “really just scratched the surface” on barriers to collaboration and other factors that must be considered to maximize the potential for success. Some of the barriers to collaboration identified by participants as being important were lack of trust, divergent goals, and difficulties in detecting and interpreting subtle and complex effects. NCI and USDA are currently convening working groups around the four research areas as well as an additional working group on the collaborative process. The groups are being asked to develop reports to share at a follow-up meeting in 2012. At another recent meeting, the Building Bridges Dialogue, participants from academia, industry, government, and public-interest NGOs were brought together, as Sylvia Rowe, president of SR Strategy, LLC, put it, to “move from conflict to convergence” around the issue of obesity. The meet- ing was organized in response to a series of previous meetings that were, according to Rowe, “quite negative in their tonality” and “lacking in a con- structive dialogue.” In Rowe’s opinion, obesity is an especially contentious issue because of the lack of a common understanding of both its causes and its solutions, including the roles of key player groups. The goal of the Build- ing Bridges Dialogue was to achieve a greater mutual understanding of the different sectors’ perspectives and priorities. The entire first half of the day was spent on discussing barriers to trust, including differences in opinion about consumer and market realities, cynicism about corporate motives, lack of candor at public meetings, and resistance to the use of new food technologies. The key outcomes of the meeting were suggestions for capi- talizing on the momentum from the discussion and pursuing next steps to- ward collaboration and future coalition development. Meeting participants identified areas for potential collaboration, such as the use of calories as a common agenda that may allow for multiple partners in multiple sectors to employ a variety of complementary actions consistent with each partner’s individual goals, and discussed needs, such as openly addressing the role of friction in the debate, building mutual trust, and defining achievable goals. However, no specific action steps were identified. As a final example of other work on which this IOM workshop built, Eric Hentges, executive director of the International Life Sciences Institute (ILSI), described ILSI’s public–private partnership initiative. The initiative has three phases: (1) produce a scholarly paper on good partnership prac-

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4 PUBLIC–PRIVATE PARTNERSHIPS IN FOOD AND NUTRITION tice; (2) overlay good partnership practices on the common top-10 research gaps among existing dietary guidelines, and identify gaps with the greatest potential to be addressed successfully through a public–private partner- ship; and (3) establish proof of principle by forming such a partnership. The initiative is currently in the first phase, with a working group putting together the scholarly paper. The growing number of workshops and initiatives on this topic re- flects a surge of interest in public–private partnering in food and nutrition research. Together, they are also building a foundation for future action. Toner remarked, “Over time, we’re hopeful that these different threads of conversation will come together and start to tell a story that can help to inform and advance research . . . a story about the positive impact that these partnerships have had on public health.” Additionally, there are several references throughout this report to the Building Trust Initiative, an innovative series of workshops with public and private actors started by Diane Finegood during her tenure as scien- tific director of the Institute of Nutrition, Metabolism, and Diabetes at the Canadian Institutes of Health Research. The first workshop was held in 2008, the second in 2009, and the third in 2011.5 The initiative has been supported by a total of $350,000 cash and in-kind contributions from a number of government, private, and nongovernmental organizations. WORKSHOP FORMAT: AN EMPHASIS ON SMALL-GROUP DISCUSSION The format of the November 1-2, 2011, IOM workshop was different from other recent Food Forum workshops, with a greater proportion of time spent on discussion, as opposed to presentation, and with much of the discussion occurring during small breakout sessions, which were designed to allow both within-sector and across-sector dialogue. Diane Finegood, professor at Simon Fraser University, and David Castle, professor and chair of Innovation in the Life Sciences at the University of Edinburgh, facilitated the large-group discussions among all workshop participants following the breakout sessions. Additionally, some of the discussion was based on results of a pre-workshop survey designed to gather information about deeply held beliefs and expectations for public–private partnerships in food and nutri- tion (Box 1-1). There were three breakout sessions over the 2 days. At the beginning of the first two breakout sessions, participants anonymously recorded on note cards their individual reflections on the topic at hand. The note cards served as prompts for discussion. At the end of all three sessions, a spokesperson 5 See www.buildingtrust.ca for information on the initiative and links to workshop reports.

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5 INTRODUCTION BOX 1-1 Pre-Meeting Survey Questions 1. Indicate the sector you feel you most represent when answering the questions below (e.g., industry, government, nongovernmental organization [NGO], and academia). 2. Please indicate any other sectors you feel your perspective represents and estimate the relative percentage for each sector (e.g., health care, 80 percent; NGO, 20 percent). 3. What is (are) your paradigm(s) (deeply held set of assumptions, values, and beliefs about the way things are or should be that established boundaries or a framework to solve problems) about multisectoral partnerships in food and nutrition? 4. What is (are) your sector’s paradigm(s) about multisectoral partnerships in food and nutrition? 5. What are the goals of your sector with regard to multisectoral partnerships in food and nutrition? 6. Describe a problem you are trying to solve that would benefit from cross-sector collaboration. 7. What expertise could other sectors bring to help solve your problems? for each breakout group reported back to the group at large key points that emerged from the discussions. The names of individuals within each group were not recorded; thus, the reflections, discussions, and report-back find- ings were recorded without attribution. The anonymity may have fostered more frank discussions than would have occurred otherwise, with a wider range of voices heard and more diverse sets of opinions expressed. The goal of the first breakout session was to continue reflecting on questions asked during the pre-workshop survey and to establish mutual understanding of the different sectors’ deeply held beliefs and expectations. Specifically, participants were asked to organize themselves by groups, with industry, government, academia, and public-interest NGO representatives meeting at separate tables.6 Business-interest NGO representatives were invited to join any table.7 There were a total of two industry tables, two government tables, one academic table, and one public-interest NGO table. The groups were asked to reflect on and discuss goals for building cross- 6 Public-interest NGOs include consumer and public health advocacy organizations. 7 Business-interest NGOs are those funded to service or advocate the interests of for-profit enterprises. As Jonathan Marks emphasized, not all private-industry partners are companies that manufacture or process foods. There are multiple types of entities even within the private sector.

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6 PUBLIC–PRIVATE PARTNERSHIPS IN FOOD AND NUTRITION sector collaboration in food and nutrition and to identify their sectors’ three top goals to report back to the group at large. The second breakout session was aimed at developing a mutual un- derstanding of how potential partners think about whether to engage in cross-sector partnerships. Participants were asked to distribute themselves by sector among six different tables such that each table had representa- tives from all four key sectors (i.e., industry, academia, government, public- interest NGO). The small groups were asked to reflect on and discuss the basis for acceptability of any proposed cross-sector partnership. At the end of the session, each table reported back to the group at large the key “metrics of acceptability” identified by its individual participants—that is, factors to consider when assessing whether to engage in a partnership. After having discussed in general terms what the different sectors hope to gain from multisectoral partnering and how potential partners from each sector make decisions about whether to join a partnership, participants were asked in the third breakout session to think about specific topics for potential cross-sector collaboration. Based on participant interest, three topics were chosen for discussion: obesity, food labeling, and calorie reduc- tion. Participants distributed themselves among the three tables, based on interest. For food labeling and calorie reduction, participants were asked to consider the goals and metrics of acceptability for cross-sector partner- ing. For obesity, participants were asked to discuss the unique challenges of obesity compared to other public health challenges and to identify goals for partnering based on their discussion. Unlike the other two breakout sessions, participants were not asked to prepare note cards of individual reflections before beginning their small-group discussions. Yet another unique feature of the workshop, as David Castle pointed out, was its focus on strategies for moving forward. He reflected that 5 years ago, a workshop on this topic would have focused on the importance of partnering and examples of successful partnerships, without delving into the “real strategic value” of such partnerships and how actually to make de- cisions about initiating new multisectoral collaborations. While this work- shop did spend some time addressing the “why” of partnering, with several presenters drawing from examples of successful cross-sector collaboration in food and nutrition research, the greater thrust of the discussion was on how actually to initiate and engage in cross-sector collaboration. REPORT ORGANIZATION AND MAJOR THEMES OF DISCUSSION This report is based partly on small-group discussions, individual anonymous reflections recorded on note cards, and results of the pre- workshop survey and partly on the workshop transcripts and presentations (see Appendix A for the workshop agenda). Many of the views expressed

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7 INTRODUCTION in this summary are those of the facilitators, speakers, and panelists, as attributed to them, and are not the consensus views of the organizations they represent, the workshop participants, or members of the Food Forum. Further, the examples provided by the facilitators, speakers, and panelists throughout this report are not exhaustive, but rather only suggestions for consideration. The remainder of this report is organized into three chapters. Chapter 2 (“Why Partner?”) summarizes the discussion and presenta- tions that addressed the benefits and risks of engaging in public–private collaboration. Throughout the workshop, individual participants across sectors identified possible risks of cross-sector engagement, including com- petitive advantages or disadvantages for one partner, actual or potential conflicts of interest that can undermine public trust, a product or activity of one partner casting a “shadow” or undermining the value of the part- nership, unequal levels of commitment or ineffective partners, the lack of control over results that are generated through the partnership, the lack of a clear return on investment when investing in research to generate knowledge, and a negative impact on individual or institutional integrity. A variety of possible risk mitigation strategies were consequently suggested by several workshop participants, including establishing clear rules of engage- ment, ensuring broad participation that includes the public-interest NGO sector, balancing public and private interests, checking brand complemen- tarity, maintaining financial transparency and legal accountability, creating an option to opt out, and conducting ongoing monitoring and evaluation of partnership outcomes. The relevance of risk and the need to consider risk mitigation when deciding whether to enter into a new partnership emerged as major overarching themes of the workshop dialogue. Chapter 3 (“How to Partner”) summarizes the discussion and presen- tations on the wide range of existing public–private partnerships in food and nutrition, with a focus on key features of success. While it is impor- tant to reflect on and understand the lessons learned from unsuccessful public–private partnerships, the workshop presenters emphasized the posi- tive aspects of enabling partnerships given the limitations of time and scope. Participants identified several features of successful public–private partner- ships, including authentic trust, mutuality, feasibility, joint planning, having clear procedural steps in place for risk mitigation and other operations, and complementarity. Several participants also emphasized intrasectoral trust can be more challenging to establish than intersectoral trust if competitors within one sector are asked to collaborate and compete simultaneously. Chapter 4 (“What Next?”) summarizes the discussion and presenta- tions aimed at providing guidance for moving forward. Participants iden- tified and tested a draft tool for assessing whether to enter into a new partnership; discussed ways to navigate the ethics of public–private part- nerships (i.e., primarily how to manage conflict of interest); and identified

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8 PUBLIC–PRIVATE PARTNERSHIPS IN FOOD AND NUTRITION some specific subjects and subject areas for potential multisectoral collabo- ration. Regardless of the specific subject, the mutual desire for more data and knowledge makes research and assessment especially conducive areas for public–private collaboration. The reader should be aware that the materials presented here express the views and opinions of individuals participating in the workshop ei- ther as presenters, panelists, or breakout group discussants, and not the deliberations or conclusions of the workshop participants as a whole, the breakout groups, or a formally constituted IOM committee. The objective of the workshop was not to address comprehensively all issues of relevance to building public–private partnerships in food and nutrition. Nor was the objective to come to consensus on any particular issue or formulate recom- mendations for future action. Rather, the goal was to serve as a mechanism for individuals from a variety of government, academic, industry, and NGO groups to openly discuss and reach a shared understanding of the different sectors’ paradigms and goals for cross-sector collaboration and a shared understanding of how to facilitate partnership development.