Choice architecture refers to how our environment is designed to influence the choices we make. In the study by Thorndike et al, healthy items (those with a green coded label) were placed at eye level in coolers throughout the cafeteria. Additionally, bottled water was placed in displays in new locations – all with the goal of increasing visibility. Is it simply enough to make a healthy choice more visible to get people to choose it? The study found that yes, at least for beverages, placing healthy choices more prominently throughout the cafeteria led to an increase in sales of those items. Bottled water sales increased 25.8% during the second phase of the study.

According to Richard Thaler (2), there are three basic principles of choice architecture. First, establish desirable defaults. Defaults refer to the the path of least resistance. Next expect errors; or design with the acknowledgement that humans make mistakes. And third, give feedback.

How can we leverage these principles to effectively nudge people towards healthier behaviours? Some interventions, such as studied by Thorndike et al have begun by modifying the defaults. The Smarter Lunchrooms Movement is another initiative with similar goals in schools across the US. Reducing the size of bowls in the lunch room, an example of changing the default, led to students serving smaller portions of cereal at breakfast. Similarly, putting chocolate milk behind the plain milk increases the difficulty of getting chocolate milk and led to an increase in the amount of plain milk sold over chocolate milk. Moving baskets of fresh fruit next to the cashiers in school cafeteria also led to an increase in their sales(3).

Can the concepts of nudges be taken beyond the school lunch room? In an upcoming post I’ll take a look at the UK Behavioural Insights Teams and the opposing views on its potential for success.

References:

1. Thorndike, A., Sonnenberg, L., Riis, J., Barraclough, S., & Levy, D. (2012). A 2-Phase Labeling and Choice Architecture Intervention to Improve Healthy Food and Beverage Choices American Journal of Public Health DOI: 10.2105/AJPH.2011.300391

2. Thaler, R. and C. Sunstein. (2008) Nudge: Improving Decisions about Health, Wealth and Happiness. Yale University Press. New Haven and London.

3.  Just, D.R. and B. Wansink (2009) Smarter Lunchrooms: Using Behavioral Economics to Improve Meal Selection. Choices 24(3)

Related readings:

• Behavioural Economics – a way to fight Big Food from Verdant Nation
• Google’s Impressive Healthy Food Program from Marion Nestle on Food Politics
• Opting In versus Opting Out by Richard Thaler

Here are this week’s favourites:

• Ever suffered writer’s block? There’s a number of nifty tools to help keep you motivated and on track to meet your writing deadlines, including one called Write or Die. If you’re prone to procrastinate, this might be for you – allowing you to set a goal (number of words to write), time limit and penalty (ranging from changing screen colour, an alarm sounding, or deleting the text you’ve just written!). Me, I prefer the idea of Written? Kitten! where typing rewards you with a picture of a cute kitten, how’s that for dangling a carrot? (Hat tip to @TravisSaunders for the link to whizbang’s post on writing tools from #scio12)
• BJ Fogg of STandford University has developed a new model to help understand behaviour change. The basic premise of the model is that three elements, motivation, ability and trigger, must occur simultaneously in order to elicit a behaviour. His research at the Persuasive Technology Lab includes projects focussed on exploring ways for computing systems to assist in changing human behavior.

Image snow day! from cory schmitz on flickr

In a large hospital cafeteria, researchers implemented a two stage experiment. In the first stage, they introduced nutrition labels that were colour coded red, yellow or green to help consumers identify the healthfulness of foods and beverages. In the second stage, the locations of foods and beverages were changed in order to increase the visibility of the healthy food and beverage choices (colour coded green).

Implementation of the colour coded labels (Phase 1) led to a significant decrease in sales of all red items from baseline measurements with sales of beverages in this category decreasing the most. At the same time, sales of green items increased, again with the greatest increase seen for beverages. Changing the visibility of green items in Phase 2 led to a further decrease in the sales of red items. However, only green beverages saw an additional increase in sales due to the rearranged product placement in the cafeteria.

As I’ve blogged about previously, feedback is important to consider in promoting behaviour change. The first phase of this study is an example of creating a new feedback loop to support individuals in making healthy behaviour changes. Menu labeling at the point of purchase is not a new idea though. Policies requiring restaurants to display calories for all menu items are popular public health interventions. However, research examining the success of these interventions in changing food choices has shown mixed results (2). Reading and interpeting nutrition labels is confusing and complex, requiring the consumer to understand kilocalories, serving sizes, and energy requirements. Additionally, the caloric value of a food or beverage is not the only determinant of its healthfulness.

The simplified colour coding used in the study by Thorndike reduces the complexity associated with identifying healthy food and beverage choices and was not determined by caloric value alone. The intervention’s success suggests that similar programs may be able to further improve the effectiveness of other menu labeling policies. However, an important challenge to this simplified approach of colour-coding healthful and less healthful foods will be reaching a consensus on the criteria by which foods and beverages are categorized.

I’ll explore choice architecture, and the effects of changing where healthy foods and beverages were positioned in an upcoming post.

References

1. Thorndike, A., Sonnenberg, L., Riis, J., Barraclough, S., & Levy, D. (2012). A 2-Phase Labeling and Choice Architecture Intervention to Improve Healthy Food and Beverage Choices American Journal of Public Health DOI: 10.2105/AJPH.2011.300391

2. Robert Wood Johnson Foundation. (2009) Menu Labeling: Does Providing Nutrition Information at the Point of Purchase Affect Consumer Behavior? A Research Synthesis, June 2009. http://www.rwjf.org/files/research/20090630hermenulabeling.pdf

Hat tip to Carrie Matteson for suggesting the article.

For additional information, please also see:

• powerpoint presentation by the authors available in pdf format 
• legal and policy resources on menu labeling from the CDC

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Here are this week’s favourites:

• In Discover Magazine, David Eagleman discusses the automatic processes our unconscious mind takes care of: “Your Brain Knows a Lot More Than You Realize“.
• This very cool project in Vancouver is a community business, looking for the community’s input in how they develop. Through a series of polls, the public will vote on what is created at “This Space“, 243 Union Street in Vancouver’s Chinatown/Strathcona neighbourhood. The winning vote from the second poll, “What type of local service do you think belongs at 243 Union Street?” was a local products grocery store. This Space is now looking for a “fresh food expert“.
• Ginger.io (a spin-off company from the MIT Media Lab) recently won a $100,000 award in the Data Design Diabetes challenge for the final development of an app that uses sensor data from your mobile phone to predict individual behaviour changes – read more about it here from Fast Company.

While some may conclude that the results of this research are no more than common sense, these findings are unique because of the methodology used, a study format called “Ecological Momentary Assessment” (EMA). Most studies that look at diet and eating patterns use recall methods, where subjects are required to remember what, how much, and when they ate at a previous moment in time. In EMA, subjects are sent a message (in this study it was via handheld computers) that prompts them to answer a specific question or questions at a specific moment in time. Subjects then are required to answer as soon as possible (reminders are sent until a response is received). The other advantage is that this method studies individuals in their natural environment, and not a laboratory setting.

The authors investigated three hypotheses:

1. Does an increased number of tasty, high calorie foods leads to an increase in eating more than normal?
2. Are individuals who are more sensitive to the rewarding aspects of food (as measured by the Power of Food Scale) more likely to over-consume?
3. Are individuals who scored higher measures of restraint more likely to resist over eating when presented with an increased availability of tasty, high calorie foods?

During an initial interview, subjects completed two questionnaires that looked at “restraint” (how much control an individual exerts over their eating) and “hedonic eating” (the desire to consume highly palatable foods): the Three Factor Eating Questionnaire and the Power of Food Scale. After an orientation in which subjects were instructed on how to use the hand-held computer as well as given guidance in identifying their normal pattern of food intake, subjects completed 7-10 days of EMA assessment. During the study, subjects received prompts via a hand-held computer to answer several questions about their most recent eating experience.

The results surprised the investigators – none of their predictions were supported by the evidence. The only significant relationship was that individuals with a higher BMI were more likely to consume more food than they normally would when there was an increase in the number of high palatable foods available compared to individuals with a lower BMI. Interestingly, the probability of overeating when high calorie tasty foods were not easily accessible was low, regardless of BMI.

The study only included young women who were in a healthy BMI range, so any conclusions must be limited to eating habits and cannot be extrapolated to risk of overweight or obesity. As the authors mention, it would be interesting to repeat the study to include a wider range of weights. Use of BMI as a measure also has its limitations, especially with a small sample size. I’m also curious if the intrusion of having to respond to the questions of the ecological momentary assessment influences the behaviour of the subjects? If subjects know that the number of times they overeat is being assessed, might they eat less?

Capturing the moments at which we make decisions related to food intake through studies such as this offers better understanding of  the reasons for over-eating. This information, combined with Brian Wansink’s and colleagues’ work on mindless eating, is invaluable for identifying strategies that will be most helpful to individuals wishing to make health related behaviour changes.

Thomas JG, Doshi S, Crosby RD, & Lowe MR (2011). Ecological momentary assessment of obesogenic eating behavior: combining person-specific and environmental predictors. Obesity (Silver Spring, Md.), 19 (8), 1574-9 PMID: 21273995

Image by jeffadair from Flickr.

Here are this week’s favourites:

• Jawbone, manufacturers of bluetooth accessories has developed the Up life monitoring wristband that will track your physical activity, sleep, and food intake. Learn more and look for it to be sold after November 6th.
• My colleague Mr Epidemiology (Atif Kukaswadia) is coordinating a blog roundtable on graduate school – be sure to check it out! Today’s post explores tips for selecting a supervisor to work with. If you’re not already, follow him on twitter too: @mrepid
• This profile in Science (NY Times) looks at the work of Dr. Michael Gazzaniga, a psychology professor at the University of California, Santa Barbara. His new book, “Who’s in Charge? Free Will and the Science of the Brain” explores the question of individual responsibility – how much of behaviour is governed by automatic processes, and where do self-directed “responsible” processes begin?

Dr. Diane Finegood will lead the discussion on Wednesday November 9^th (7:30 – 9 PM) at Central City Brew Pub next to the SFU Surrey campus. She will be accompanied by the Chief Medical Officer of Fraser Health (Dr. Paul VanBuynder) and the Vice President of the Canadian Restaurant and Food Services Association (Mark Von Schellwitz). Fast food giants are often blamed for driving the epidemics of obesity and chronic disease, but in a fast paced world with rising food prices they provide a convenient and cheap source of calories. Can these giants change to meet our need for a healthier food supply and whether we as consumers will help them change?

Admission is FREE and appetizers will be provided.

Atif introduced the panel on Friday, also listing the questions that we’ll discuss in upcoming posts. Monday’s post began the roundtable with an exploration of why each of us decided to continue our education after completing an undergraduate degree. The series will continue with questions and responses from the participants through November.

I hope you enjoy the discussion!

My apologies for the delay in resuming regular posting, and sharing more of my experiences from TOS. I also attended the pre-conference session “Food Industry Outreach— Strategies the Food Industry Is Using to Address Obesity. Marc Andon of Con-Agra, Doug Ballantine of Unilever, and Richard Black of Kraft Foods each spoke about initiatives from their respective companies.

A key message from Marc Andon was that the potential for single serve meals (from companies such as Con-Agra) as a helpful strategy for portion control is under-utilized. The misperception that such frozen meals are high in calories was provided as one explanation of why many might shy away from using them. Personally, I think cost would be a bigger factor.

Doug Ballantine spoke next. While a crowded slide listed multiple players involved not only in the travel of food from farm to fork, but also educators, government, caretakers, etc… there seemed to be stronger emphasis placed on the role of the consumer and the importance of personal responsibility. Unilever sees their role as to help lower calories, improve taste and quality, add nutrients, remove sugars and fats, and add vegetables.

The message that stuck with me most from the forum was on how foods are marketed, a story shared by Richard Black: how do we sell “healthy”? Ritz crackers labelled as “Low Sodium” were a flop…yet, the same cracker, in the same package, with only the label changed to “Hint of Salt” did sell. This echoes another example from Doug Ballantine on how the formulation of Ragout tomato sauce has changed to reduce sodium, sugar, and increase the tomatoes, all without changing the label or marketing it differently. We are asking people to dramatically change what they eat, how they buy foods, and how they prepare them…and this process requires lots of patience and time.

Doctors of Weight Loss also provide an excellent summary of these presentations on their site.

Following on the heels of this session, Sunday was the “Food Industry: Friend or Foe” debate between my supervisor, Dr. Diane Finegood and Dr. Yoni Freedhoff. The Obesity Society has allowed Yoni to post videos of the debate on his blog, available here for viewing.

A few other recent and relevant posts from Dr. Freedhoff:

• The food industry and health. Not even remotely on the same page
• Coca Cola the Corporation vs. Coca Cola the Individuals

Also from, Dr. Arya Sharma, “Can an Obesity NMGO Take Money from ‘Big Food’“. The discussions following his post highlight the need for “thoughtful lines in the sand”.

Here are this week’s favourites:

RSA is an organisation that strives to help find practical yet innovative solutions to current problems and make the world a better place.Part of their mission is to share great ideas with a wide audience, and they do this in part through lectures, and some of these are set to fabulous animations.  If you haven’t ever listened and watched one, here are three to get you thinking:

From RSA Animate:

1. The Secret Powers of Time: Are you present oriented or future oriented? How does that affect your health behaviour choices?

2. Drive: The Surprising Truth About what Motivates Us

3. Choice