Shireen:  Dr. Anne Thorndike talks to us and helps explain to us what behavioral economics and choice architecture is, how we're surrounded by it and making our day to day decisions at the workplace as well as at the grocery store, and what we can do differently in utilizing choice architecture to be applied on a more micro level in our homes. Dr. Ahn Thorndike is an associate professor of medicine at Harvard Medical School and the director of the metabolic syndrome clinic at Massachusetts General Hospital. Her research focuses on individual and population behavioral interventions to prevent cardiometabolic disease. Through implementation research, her team has demonstrated the effectiveness of traffic light labels, choice architecture, social norms, and financial incentives to promote healthy food choices in real life settings, such as worksite, cafeterias and supermarkets. Welcome Dr. Thorndike. 

Dr. Thorndike: Thanks so much for having me, an absolute pleasure. 

Shireen: So diving right in, I want to ask you, what brought you to the field of health sciences and then specifically within that behavioral economics and choice architecture?

Dr. Thorndike: So I came to the field of health sciences as a physician, I wanted to be a physician ever since I was a young child. And so when I became, when I went to medical school, I was very much interested in prevention. And then I went on to do an internal medicine residency and went into primary care and during that time, as I began my practices, primary care I was, again, I continue to be interested in prevention, particularly in preventing weight gain and obesity and all the chronic disease related to that. And so my research started to, in my research, I started to think about those factors. And what really began to impress me over time in practice is that those 15 to 20 minutes I spent with a patient once a year, couldn't match up to what people were exposed to in their environment. And so my research started to move more into what could we do outside of the medical office to help people make healthier choices. So I really wasn't interested, introduced to behavioral economics until about 11 to 12 years ago, when I began working on our employee wellness programs at Mass General. And we started to put together a project that would be trying to help people make healthier choices in the cafeteria. And I ended up reaching out to a Harvard Business School professor who, to work with me on a research grant. And he really introduced me to this concept of behavioral economics and choice architecture. And at that time, it just all of a sudden, it clicked with me that that made a lot of sense for doing a population intervention to promote healthy food choices. And so from there, the rest of my research was really focused on these types of interventions.

Shireen: So just a little bit for our listeners to understand, can you provide us a brief explanation on what exactly behavioral economics is and also choice architecture? 

Dr. Thorndike: So behavioral economics isn't one thing, it's a, it's a field of study. So we, we know a lot about traditional economics and traditional economic theory really focuses on the fact that you can provide people with information and they will make choices, they will make a rational choice on what's best for them. Behavioral economics, on the other hand, makes, makes, doesn't make that assumption that we always make rational choices, it makes the assumption that sometimes we we don't make rational choices, and that the interventions based on behavioral economics are to nudge us towards those choices that would be good for us that we we probably want to make anyway. But we don't always make in the moment. And so choice architecture is one intervention that has been brought to the forefront by behavioral economics that's really, in what I do. The choice architecture is really about product placement, putting something in a place that's easy to see or easy to reach. But it could be if you were making a choice about health insurance, that it's putting it at, the making that, listing the one that we really would be better for you to use, at the top of the list rather than the bottom of the list. Or if you were reading a menu, put the healthy choices at the top of the menu rather than at the bottom of the menu so that you see them first. So it's making the healthy choice the easy choice.

Shireen: And so if I'm understanding this correctly, so essentially, the making the healthy choice, the easy choice helps people make better decisions. 

Dr. Thorndike: Yes, that's the idea. 

Shireen: Okay. Okay, that's helpful. So what has your research shown about utilizing choice architecture on a macro level, to improve our food choices?

Dr. Thorndike: So a lot of my research, using behavioral economics to promote healthy food choices has been in the context of the workplace environment. In particular, I've done a lot of work at my place of employment, Massachusetts General Hospital, it's a very large hospital with over 26,000 employees. We have a large cafeteria at plus several other smaller cafeterias, which people use quite frequently. We don't have a lot of other food vendors, we don't have any other food vendors on site. So we are able to study what people purchase in our cafeterias when they use their employee ID card, and many employees do use their employee ID card, be, just because it's easier. So initially, back in about 2009, when we first started doing this work, we were thinking about what would help people in the moment as they're making a food choice to make a healthier choice. So combining this concept of choice architecture, which is really about placing the items, we also implemented a program using traffic light labelings, and we call it choose well eat well. And the idea was that we would be nudging people towards a healthier choices. So the green items were, we labeled them to choose frequently, whereas the red items, we would say there's a better choice in green or yellow, yellow was really middle of the road. And so we implemented the traffic light labels first. And then three months later, we implemented choice architecture changes, where we put a lot of the green items at eye level, or we put next to the pizza station, we've put box boxes, small boxes of salads, so that encourage people to buy one slice of pizza and a salad rather than two slices of pizza. And so what we found in that in our very first study was that if we compared the, we had three months of baseline data before any changes were made, then we had three months of traffic light labeling only followed by three months of traffic light labeling, plus choice architecture. And we found that compared to baseline in each three month block, the green purchases increased and the red purchases decreased. Now our whole labeling was developed by our nutrition staff, and it's based on USDA guidelines. It really emphasized foods that were, had fruits and vegetables as a main ingredient that were low in saturated fat. They were lean protein or low fat dairy. So what we, what we found is that people were made, making purchases, purchasing healthier items with these changes. And then we followed up in two years to see did those changes stick? Because one of the arguments often is if well, if you label things people do great at first, and then they get tired of it. But what we found is that two years, they were still doing better, and that they hadn't reverted back to their unhealthy choices. So to me, that was the best news. And we also did an additional study where we looked at the calories purchased, and we saw that overall, people were purchasing fewer calories when after the intervention.

Shireen: Interesting. And so essentially, the idea then is that if you educate if you're able to make it very easy for them to essentially the understanding exactly what those labels or even what those food items need to look like. The decision becomes very easy and then also repeatable after.

Dr. Thorndike: Yep. And I think one key thing that I like to always emphasize is that there's nothing more effective than the Red Label. This is, this is what people want to avoid. And it's not that people who want to get french fries no matter what aren't going to buy them or, or can't buy them. It's really for the label for people who were really on the fence about the french fries, but they were kind of looking tempting, but the Red Label just reminded them, that that's not consistent with what they really want to do, and that maybe the, the roasted potatoes or the roasted sweet potatoes that are not red, a red labeled item would have are a better choice.

Shireen: So, you know, when you, when you mentioned this and this being effective, immediately my mind goes to “Well, why isn't this a standard in grocery stores?” For instance? What would you say to that?

Dr. Thorndike: I would say it's complicated. Now, I agree, like, why isn't the standard in our food labeling, just in general, to have something a lot simpler, the, you know, food labels that we have now provide all the information, we need to make a healthy choice. They're excellent, they provide great information. But in all reality, most people aren't taking the time and don't have the time or may not understand how to interpret those labels. So we really wouldn't be better off with a much simpler labeling system where we could see right there, “Instantly, what is the better choice?” Now we've tried a little bit of this in grocery stores. So we, we will have our first of all, we tried choice architecture in corner stores in a community next to Boston that was mostly low income, income, predominantly Hispanic community. And we worked with corner stores to put fruits and vegetables at the front of their store. And so these corner stores, they're tiny, most of them, a lot of them had like one store had a huge chip rack with Doritos, and everything at the front of the store. And another store had a lot of pastries, and you know those types of things. So we had to work with the stores to get them to agree to do this. And we randomized three to get this intervention and three to to not have the intervention. And what we looked at for outcomes was whether people use their WIC, fruit and vegetable vouchers to buy fruits and vegetables in their store. And we did see that in the stores that we put the fruits and vegetables at the front of the store, I made them easy. And we helped the stores to make it look appealing. We gave them, we gave the baskets and good places just to stock them. And that, that did result in increased purchase fruits and vegetables in those stores. So that was a very simple intervention that did appear to work. Now if we would need a bigger study a longer term trial to know if that really worked over time. But I thought it was pretty effective. We did another study in that same community where we worked with a medium sized grocery store to do the traffic light levels on their beverages, and also provide financial incentives to get people to purchase fewer red labeled or unhealthy beverages. So the reason why I know it's complicated to do this labeling is that in this relatively small grocery store, there are over 700 different beverage items, because different sizes, different types, different types of sodas, different types of juices, powder, drinks, and all this. So it did take a fair amount of work to determine all the labeling. And I think that's, that's the hard part is that you know, for grocery stores to implement this on their own is nearly impossible because of the number of different products. However, shelf placement is something that stores could be doing. I also had written an opinion article about, about using the end caps in grocery stores that, that stores that provide food for people who use snap or food stamps, should not be allowed to be putting all the soda at the front of the store or candy on the end caps. Because this is just making it easy for people to buy these items. And there is some indication that stores do this at the beginning of the month when SNAP is being issued to people like they're, they're targeting people. A colleague of mine did a study showing that, that stores tend to put out their sugar sweetened beverages at that time when the SNAP is issued. And I don't think that should be allowed. I think we could have policies that use choice architecture a little bit better to make sure that people on SNAP benefit, but that the rest of us benefit as well. It's not targeting necessarily people on snap, but it would affect all of us. 

Shireen: Interesting and then just from the policy standpoint, who would, who would potentially make such policies and enforce them? 

Dr. Thorndike: Well that, the reason to to be talking about SNAP is because then the policies would be at the, probably the federal or state level, and would have to be enforced. Now, that raises a whole other set of issues about enforcement. However, you know, there are examples of it, it for at least in Massachusetts for tobacco products, there were rules made around how you stock tobacco in stores. And so they had to be behind the counter or they, you had to take away those power walls that they used to have. And so there is precedent for things like that being done, it would just, it would be a little bit of a bigger ask, because there's a lot of different types of unhealthy beverages. 

Shireen: So how can your research findings about utilizing choice architecture be applied on a more micro level, for instance, into the home itself to make better food choices?

Dr. Thorndike: So I haven't done any particular studies in, on the micro level, but I have a lot of ideas, and I have a lot of things that I counsel my patients about doing. So the number one best choice architecture that anybody can do is to not bring the food they don't want to eat into the home. So don't buy it at the grocery store in the first place, then it's not your home, you're not going to eat it. However, I do acknowledge that many people don't live alone, that you don't have full control you need to buy for other people in the household. So it's not always so straightforward. But there, there are little things that people can do to maybe restructure their home environment that might make it easier for them not to make unhealthy choices. So you can identify a drawer or a cabinet where you put the cookies and chips or something that maybe you're buying for somebody else in your household that you don't want to you don't want to eat, you want them out of sight, you want them hard to reach. You could have a drawer where you put only your foods for yourself that you know are consistent with your, what you, what you want to be eating. And you say, well, it's off limits to other people, this is my food, and I'm not going to not going to go for the other things. Another potential way for people to use choice architecture individually, and this is something with our group has thought about a lot is it, through online shopping. So that if you, rather than going to the grocery store and being tempted by everything in the aisles, if you go online with a list, and you're just searching for what you want, then it reduces a lot of temptation for buying things that you may not have planned to buy in the first place. So really, the planning is really important. Now there, are there is some evidence that there might be a little bit of marketing online, so you have to watch out for that for, for the unhealthy items. But for the most part, if you stay, stick to a list and go online that could help you.

Shireen: Any other tips in our environment around us just designing this in a healthy sort of environment around us in making the best choices for our health.

Dr. Thorndike: I think that it really, we, it's not… We have to get over the idea that it's all about our own willpower, we really need to set up, set ourselves up for success. So if for you or anybody walking by Dunkin Donuts triggers you to want a sugary beverage and a doughnut, try not to walk by Dunkin Donuts, like really understand that about yourself. If going into the grocery store, every time you walk by the bakery and you smell all the breads and cookies or whatever, and that is a trigger, try to stay away from that area of the grocery store. I think that in the grocery store is of overwhelming place for all of us. There's lots of temptations there and trying to navigate the grocery store and avoid those areas where you're going to be tempted stay out of the aisles that are going to have just all the cookies or things that you don't want to be buying. You know, it's, it's not always so easy. But you know, the idea is to stay on the perimeter of the grocery store where those, the, the fruits and vegetables and as well as the thing you know, the lean meats and the dairy and all of that. 

Shireen: So with that Dr. Thorndike route toward the end of the episode, how can our listeners connect with you learn more about your work?

Dr. Thorndike: Um, well, I think what well, what I can do is provide some research articles that describe what we've done. Our, all of my work has been done in settings that I call real world, meaning that it's not artificial. All the changes that we made at Mass General Hospital are still in place. They were, we did it 10 years ago and they're still using the traffic light labeling, and the choice architecture. So these were made as permanent changes. And so I know it can be done and maintained. And so, so yeah, so I can provide you with some article links. 

Shireen: Oh, that'd be great. And so what we can do is, in our show notes, for this episode, we can, we can add those links there. So we'd love to even get the the publish, if you have, if you can share those links, as well as the opinion piece that you talked about more for the sort of the choices at home, it would be, it would be great to get those as well. 

Dr. Thorndike: Yes, no problem. 

Shireen: Great, we'll get that added on for you. So to our listeners out there, go over, head over to our social media, and tell us, you know, the one item that you can make a change within your daily lifestyle, one habit that you can change. Tell us about… Tell us about it over on social media, you can find us at young English, on Instagram, as well as on Facebook, and we'll find you there. With that, Dr. thorndyke. Thank you so very much for coming on the episode today in sort of providing us this information and sort of helping us make us even more conscious of our environment so that when we go into the grocery store, we're sort of not, you know, we don't have those blinders on. We're now more aware of what's around us and how items are catered to us so appreciate your time on that. 

Dr. Thorndike: Great, thank you very much. It was really a pleasure.

Find Dr. Thorndike's work!

Obesity Prevention in the Supermarket-Choice Architecture and the Supplemental Nutrition Assistance Program

A 2-phase labeling and choice architecture intervention to improve healthy food and beverage choices

Choice architecture to promote fruit and vegetable purchases by families participating in the Special Supplemental Program for Women, Infants, and Children (WIC): randomized corner store pilot study 

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