Designing with the grain: making healthy living easier
www.nesta.org.uk/project-updates/designing-grain-making-healthy-living-easier/
www.nesta.org.uk/project-updates/designing-grain-making-healthy-living-easier/
Many of our food choices are not conscious, deliberative decisions but instinctive responses to our environment.
Although we might feel that we freely choose the food we eat, our eating behaviour is heavily influenced by the availability and convenience of food, prompts in our environment, and the social and informational landscape around us. We are no match for our current food environment which pushes us towards buying and consuming unhealthy food that is affordable, easily accessible and readily available.
The result is a public health crisis: 63 per cent of English adults are overweight and 28 per cent are obese.[1] Excess weight increases our risk of high blood pressure, type 2 diabetes, heart disease, stroke and cancer.[2] Ultimately, this translates into higher mortality rates; diet and high body mass are the second and third highest risk factors for life lost, the first being tobacco.[3] However, this loss of healthy life is not evenly distributed among us. Obesity rates are 80 per cent higher in the UK’s most deprived areas compared to the least deprived.[4, 5] This disparity begins early; a five-year-old in one of the UK’s most deprived areas is more than twice as likely to be obese than their wealthiest peers.[6]
We must ensure that our environment – the places we shop, the foods we buy, the streets we walk on – makes healthy eating easier.
Fundamentally, obesity is on the rise because most of us consume more energy in the form of calories than we burn through physical activity. Food, of course, means more to us than just caloric energy, but this suggests two approaches to tackling obesity: reduce calorie intake or increase physical activity. Whilst physical activity should be promoted for a variety of health reasons, evidence suggests that reducing excess calories is the key to tackling obesity.[7] Indeed, Public Health England estimates that the average adult consumes 195 excess calories each day, the equivalent of just one 40g bag of crisps or a pint of beer. This increases to 320 excess calories for people who are overweight or obese.[8]
The consequences of obesity do not only impact the individual; in 2014–15, the NHS spent more than £6 billion tackling the direct consequences of obesity.[9] More recently, the COVID-19 pandemic has provided yet more evidence of the devastating consequences of excess weight. As Public Health England recently reported, obesity is the single greatest modifiable risk factor for COVID-19 hospitalisation, after nonmodifiable factors such as age.[10] All else equal, the relative risk of critical illness from COVID-19 more than doubles for patients living with excess weight or obesity.[11, 12]
To protect the nation against COVID-19, the government has recommitted to tackling obesity. Doing so effectively requires rethinking and rebuilding our food environments with human behaviour in mind.
For decades, the narrative around obesity assumed that people make a conscious choice to overeat and not exercise. However, the truth is that our food environments have an enormous influence on the choices available as well as the options we choose. We all tend to eat what is in front of us until it is gone. What is in front of us is often determined by our habits and routines, which are heavily influenced by our income, external cues, social settings and the environment around us.
We have all been in situations in which we intend to do something, but are pushed in the opposite direction. We may intend to cook dinner from scratch, but when tired returning home from work we pick up a takeaway at one of the many outlets on the way. Similarly, we may not plan to snack after school, but our friends want to meet up at a shop on the high street. Or, we may plan to buy fruit at the supermarket, but when we enter our local store the price of fresh produce is up, while our favourite biscuits are on promotion.
Our choices are heavily influenced by the environment around us, and our food environment has undergone a rapid transformation. It is now incredibly easy to access tasty, but calorie-dense, food from an array of outlets on our high streets. The number of fast food outlets has increased[13] and portion sizes are often larger than those sold by retailers.[14] This is particularly apparent in deprived areas, which have a higher density of fast-food outlets.[15] Unhealthy food is also widely advertised and promoted, nudging us towards buying and consuming excess calories.
The detrimental impact of our environment on our weight is exacerbated by our increasingly complex and busy lives. High cognitive strain, time pressure, financial worries and other stressors can lead to less healthy food choices[16], and impede efforts to be physically active.[17, 18] The basic principle is this: when we are under strain or have little time available, we are likely to find it particularly difficult to make health-conscious choices; we default to what is most attractive and easily available in the immediate environment.
In short, when it comes to food consumption, willpower, education and attitudes to eating are no match for obesogenic food environments.[19] As such, the physical, social and informational environment within which we find ourselves must ensure that the healthy option is the easy, default one.
To tackle obesity, we need to create a food environment that is designed with human behaviour in mind to make it easier to choose the healthy option.
In the past, we’ve seen environment-focused approaches used effectively to address health issues. Arguably, the most impactful change to public health policy was the 2007 ban on smoking in all enclosed workplaces, including bars and restaurants. This policy was built around an understanding of the nature of smoking behaviour – that it is inherently habitual and often social. By making it inconvenient and anti-social to smoke – ensuring our physical, social and commercial environment makes it harder to be unhealthy – the ban achieved its aim with immediate effect; there was a 6.3 per cent drop in the volume of cigarettes sold in England in the 3 months after the ban was implemented[20] and rates of smoking have steadily declined since.[21] This policy approach did not create a backlash either. Since the smoking ban was implemented, there has been increasing support from the public for even stronger measures to reduce smoking.[22]
Our approach to tackling obesity in the UK must be similar.
Imagine a world in which the food available to us is reformulated to be healthier and keep us fuller for longer. A world in which healthy foods are available and accessible to everyone because they are cheaper and more abundant. A world in which we can all make better choices about the food we eat and where we shop based on easy-to-understand nutritional labelling and reliable information on which shops will support us in making healthy choices. A world in which we are not unfairly influenced by adverts, in-store promotions and attention-grabbing positioning of the unhealthiest food. A world in which the healthy option is the easier option for everyone.
Policies need to focus on environmental changes that support people in making healthier ‘marginal’ choices, but also harness the power of market forces to push industry to develop and promote healthier versions of similar foods, ensuring the options available are universally healthier for everyone. For example, when faced with ice cream in a supermarket aisle, very few of us will turn back to the vegetable section and select carrots instead. However, some may be prompted to choose frozen yoghurt as a healthier alternative to ice cream. If enough consumers make this substitution, retailers will begin to stock more frozen yoghurt and less ice cream. Producers will shift production, looking for healthier varieties of dessert. Thus, more and better varieties of healthier options become widely available and the market changes.
Critically, built into this approach is a focus on reducing health inequalities. Constrained choice, education levels and the burden of financial strain all contribute to obesity-related health inequalities. Instead of urging individuals in disadvantaged areas, where obesity prevalence is greatest, to purchase healthier foods or exercise more, an environment-focused approach puts the onus on policymakers, retailers and producers to ensure our environments support our health.
Additionally, by focusing on shifting our food environment, we can tackle obesity without removing pleasure from food or amplifying disempowering narratives about body image, both of which have had little positive effect on reducing obesity and may have negative consequences on mental and physical health.
To tackle obesity we need a combination of innovation methods, unusual coalitions, experimentation and government leadership through policy. The measures set out below are examples of how an environmental-focused approach can be used to support healthier marginal choices and shift consumer demand. While the UK Government’s new obesity strategy[23] acknowledges that the environment we live in plays a huge role in shaping what we eat, these are the kinds of bold changes that the government should consider to take the obesity strategy further.
There is a particularly strong case for focusing on product reformulation as it does not require us to change our eating behaviours or food cultures. We can eat the same products, consume the same amount and enjoy the same traditions, but with fewer calories. Evidence shows that consumers tend not to notice reformulation; eating fewer calories and yet feeling just as full. The Sugary Drinks Industry Levy or ‘sugar tax’, for example, took 28 per cent of sugar out of the UK’s soft drinks market without impacting sales or satisfaction.[24] Portion size reduction also shows potential; evidence suggests that calorie intake would be reduced by around 14 per cent in UK adults if large food portions, packages and tableware were not available. [25]
Following the success of earlier salt and sugar reduction programmes, Public Health England has been working with food producers to reformulate and reduce the portion sizes of those food types which contribute to around 50 per cent of children’s daily calories.[26] However, there are significant technical challenges in solid food reformulation, and issues related to interfering with market competition.
For some high fat, salt and sugar foods there may still be a case for direct regulation, such as well-designed taxes or levies. Learning from the success of the Soft Drinks Industry Levy (SDIL) or ‘sugar tax’, the design of any tax should carefully select thresholds that industry can feasibly reformulate to meet. By encouraging reformulation, the benefits of reduced levels of fat, salt or sugar can be distributed equitably and not just enjoyed by the most health conscious among us.
Whilst there are obstacles for reformulation of some products, it may be possible to catalyse market innovations and diffusion through other means. For example, challenge prizes could be used to find new ways to produce food that is considered hard to reformulate with business-as-usual R&D alone.
Another approach would be to harness market forces to encourage reformulation. Offering attractive, cheaper and, crucially, healthier alternatives can nudge consumer demand. Like substituting frozen yoghurt for ice cream, if enough consumers choose the marginally healthy alternative, retailers will shift the items they stock and producers will shift production to cater for the healthier choices.
Collective intelligence, such as citizen-generated data [27] about which foods different cohorts of people would find acceptable to substitute, can be used alongside data on food purchasing and pricing to target foods that would most effectively drive producers to reposition or reformulate in ways that consumers wouldn’t mind (or even notice).
It is this idea of using marginal shifts in consumer demand to drive changes in product formulation, size, price and positioning that is central to making it easier for everyone – no matter our circumstances – to live a healthy life, without taking the joy out of food.
Unhealthy food is widely advertised and promoted, nudging us towards buying and consuming excess calories. The government’s new obesity strategy [28] outlines plans to implement a 9pm curfew, as well as consult on a possible total ban on online advertising of high fat, salt and sugar products. The case for restricting the advertising of unhealthy food is compelling. Even after accounting for potential losses to broadcasters, advertisers, manufacturers and retailers, the introduction of a 9pm curfew for junk food advertising is estimated to result in a net gain of £2 billion. The health benefits for the individual, cost savings for the NHS and social care, and increased economic output due to reduced premature mortality are estimated to outweigh the potential losses.[29] Moreover, we would not be constantly bombarded with unhealthy food advertisements.
The obesity strategy also confronts how food is marketed and promoted in stores, with plans to end promotion of high fat, salt, and sugar products by volume (such as ‘buy one get one free’ deals) and location (such as prominent displays at shopping tills or end of aisles).
Regulating advertising further, beyond the curfew, could also help to drive product reformulation. By banning advertising and promotion of the most unhealthy foods, particularly those highest in fat, salt or sugar, and also instituting lighter restrictions on the next band of unhealthy foods, the government could drive progressive reformulation across these boundaries – similar to the way in which the tax bands of the sugar tax drove reformulation of soft drinks.
In addition, relatively little is currently known about the impact of advertising online compared to traditional broadcasting. In order to help inform the proposed consultation of online advertising, it will be important to understand how many online ads different individuals see, and the relationship between ad types and lengths, increased purchasing, and eating behaviour. For example, we shouldn’t assume that a five-second advert is only one-tenth as effective as a 50-second one, but without knowing more about the dose-response of online ads, the government cannot make informed, effective policy.
For in-store marketing and promotion, collective intelligence and behavioural insights can help inform further product positioning and promotions that drive consumer choice in this changing landscape of marketing. Experimental trials in real-world settings – including in partnership with larger chains, small convenience shops and international food stores – can help test changes and evaluate impact for diverse consumer groups. Additionally, there is potential to take regulations further by linking nutritional labelling to prominent positioning in-store. For example, banning any products that score ‘red’ on nutritional labels from being at eye-level, particularly for children.
Policies targeting individual behaviour change need to be designed with an understanding of human behaviour, adopting a strategy of substitution, rather than expecting large step changes in behaviours. Even the relatively small reduction in calories in a ‘marginal choice’, if scaled to the majority of the population, will have a large impact.
An experimental study by the University of Cambridge reported that, when online shopping, one in four suggested swaps were accepted by consumers.[30] Small changes to the architecture of supermarket websites are likely to feel acceptable to consumers, supporting them in making healthier choices whilst maintaining clear autonomy. This seemingly innocuous approach – offering a healthier alternative – if taken to scale, would immediately take calories off our plates.
To support consumers in making marginally healthier choices, we need helpful and easy to understand nutritional information. In isolation, nutritional labels have only modest impacts on consumer behaviour, but front-of-pack heuristics, such as the colour-coded Nutriscore labels, have shown promise.[31, 32] The government’s new obesity strategy acknowledges the importance of front of pack nutritional labelling, with plans to publish a public consultation on the current UK labelling.
A more ambitious step to support consumers in making healthier choices could be to go beyond individual products and to sharpen competitive pressure between retailers and food outlets. Most UK consumers have multiple choices of where to buy food and these retailers and out-of-home food outlets compete aggressively. Offering consumers more reliable information on which of their local retailers offer healthy products may tilt the balance of competitive pressure in favour of healthier options. Information provided could include to what extent retailers focus special offers on healthier foods, put healthy food in more prominent locations, and stock healthier products. Sharpening competitive pressure offers an under-utilised approach to shifting consumer demand, and warrants further exploration. What’s more, this information could also be used to set zoning and licensing thresholds, enabling local councils to ensure every neighbourhood has adequate access to healthy choices.
Healthy substitutions and effective information on how healthy our food and shops are will impact individual consumer choice, but they also drive a secondary form of impact; producers will be encouraged to reformulate their products to avoid substitutions or an ‘unhealthy’ label, whilst retailers will make changes to receive a more competitive ‘healthy’ rating. While initial demand might shift most amongst those who make a conscious decision to choose a healthier alternative, the resulting reformulation and changes to our food environment would have a positive effect on all consumers, thereby helping to address health inequalities.
While we must not lose this critical window to achieve change through policy, we also must not forget the lessons we have learned about why good, healthier alternatives often fail to scale, including, all too frequently, a lack of consideration for demand. So how do we know what alternatives would be desirable? And how do we ensure that alternatives still enable our plates to reflect our food cultures, traditions and desires?
One way of finding out might be to use food consumption to recommend smart substitutions. For example, supermarkets can use nutritional information on their products to figure out which foods might make good, healthy substitutes. By combining this nutritional analysis data with wide consultation about what people actually want and buy, it is likely these recommendations can be sharpened. For example, nutritional analysis alone might suggest that cottage cheese could sub-in for cream in many recipes but it’s very unlikely a person would accept this as a suggested swap. On the other hand, learning how diverse groups of healthy consumers swap might reveal alternatives that aren’t obvious from a nutritional profile alone.
By using data science and innovative consultation methods in partnership with shop owners, food producers, health experts and consumers, we can jointly identify alternatives we want to eat, stocked in the places we shop. In doing so, the change in consumer demand required to marginally shift our food choices is within reach.
Alongside this, we need to design an impactful front-of-pack nutritional label built on a realistic model of how consumers – of all levels of education and food literacy, and with diverse cultural backgrounds – will interact with information, rapidly and at a surface level. For example, we might consider simplifying labels by using summary or interpretive information, keeping a colour system to attract attention and aid interpretation, and ensuring a single labelling modality is used across products and settings (in addition to back-of-pack calorie and nutritional information).
To encourage healthier choices, labels that emphasise excessive unhealthy nutrient levels are more effective than those that promote the health benefits of alternative products, driving consumers away from unhealthy products.[33] The inclusion of additional nutritional measures, such as satiety – the measure of how full you will feel after eating – should also be considered.
Innovative methods and robust testing should also be used to explore the possibility of healthy eating ratings for stores and food outlets. First, collective intelligence tools can help us understand what factors influence the decision on where to shop, what information would be useful to consumers, and how this differs across the population. Designing a rating system that is easy-to-understand and helpful would be crucial, as would extensive and robust testing in real-world settings.
In developing new nutritional labels, the threshold at which nutrients are classified as ‘red’ should be carefully considered in order to encourage the reformulation of products and avoid consumer-deterrent ‘unhealthy’ labelling. Similarly, the characteristics of stores or food outlets that lead to a less healthy food environment rating should aim to encourage retailers to make reasonable changes to receive a more competitive ‘healthy’ rating, and be accompanied with reasonable measures to support small and independent shops to adapt.
Selecting appropriate ‘unhealthy’ criteria to drive change and designing labels and food environment ratings that are acceptable and impactful for consumers will require unconventional partnerships amongst government, industry, retail and consumers. Collective intelligence, behavioral insights, and experimental methods are crucial for ensuring that labels and ratings are designed for harm reduction and are effective in shifting consumer behaviour.
With the government’s renewed focus on tackling obesity, now is the moment to be bold. Our food environment must be redesigned with human behaviour in mind whilst avoiding removing the pleasure from food or requiring constant attention to food choices.
Instead, we need an environment-focused approach that will encourage retailers, producers and consumers to produce and demand fewer calories. Innovative methods, including behavioural science, data science, innovative financing and collective intelligence offer powerful tools to inform policies that both support people in making healthier ‘marginal’ choices and also harness the power of market forces to push industry to develop and promote healthier versions of similar foods.
Importantly, by minimising the associated time, effort and costs of making healthier choices, an environment-focused approach can reduce the constraints that low income places on healthy eating, reversing the rising trend in obesity levels without widening health inequalities. In other words, supporting everyone to live well.
During the COVID-19 pandemic, we have all shown extraordinary willingness to accept changes to our environment as part of the effort to protect public health. Now is the time to be bold and tackle our food environment, changing the architecture of our daily lives to go with the grain of human nature, making it easier to live healthy lives.
