Healthy Environments

This talk was delivered in a conference called Childhood Health, looking at interventions to make to tackle the problems of childhood obesity. Childhood obesity is a huge problem in the UK, with a huge cost to the economy which is only due to increase over next 40 years. Watch the full presentation below, or read a narrative based on the principles within the talk.

My brother was a 1970s child, a time in which a massive societal backlash against sugar was occurring. As a result, my mother greatly restricted the amount of sweets he could eat in the home, believing she was doing him a great favour to his health. The thinking, of course, was that he would not get into the habit of eating “junk food”.

Imagine her surprise when, one day, she saw him on his paper round, now a young teenager, stuffing himself with sweets one after the other, as fast as they could go in his mouth, bought with his hard earned cash.

Sometimes, it seems, an attempt to clamp down and control certain behaviours just causes a pressure valve to open up elsewhere. We’ve seen it time and time again. Prohibition of alcohol in the US may have temporarily decreased supply of alcohol, but it caused other issues:

“When Prohibition was introduced, I hoped that it would be widely supported by public opinion and the day would soon come when the evil effects of alcohol would be recognized. I have slowly and reluctantly come to believe that this has not been the result. Instead, drinking has generally increased; the speakeasy has replaced the saloon; a vast army of lawbreakers has appeared; many of our best citizens have openly ignored Prohibition; respect for the law has been greatly lessened; and crime has increased to a level never seen before.” – John D. Rockefeller, Jr.

Our healthy eating policy in schools right now often amounts to a similar prohibition. In the fight against childhood obesity, we have banned the processed burger, the chocolate, the fizzy drinks and crisps. We have limited the amount of deep fried food like chips that are available. And perhaps this is right, but one wonders if instead, we have simply pushed the problem elsewhere.

What if instead, we could begin to influence more healthy choices and options? What if we could nudge young people towards choosing better diets, and doing more exercise? What role could our schools and other facilities that interact with young people play?

Healthier dining experiences

It turns out that even the availability of healthy options increases their uptake. In the US, experiments with introducing salad bars into schools has seen a 38% rise in choices of healthy foods.

If we then pay attention to how the healthy items are positioned on a counter, in terms of their placement in line and their positioning at eye level, we can see consumption increase by 25% – or indeed decrease, if they are not positioned well enough.

Yet we can go even further. As I discussed in a previous blog posting, a different experiment found that by simply locating the salad bar near the cashier, healthy food uptake increased by 300%. It’s the kind of impulse buying we find in supermarkets, but used in a positive way.

This is all because of something that is often referred to as behavioural economics, or as the authors of Nudge, Thaler and Sunstein call it, “choice architecture”. By thinking about the way we design environments, we can influence positive behaviours and choices.

If this seems manipulative, it is because it is. Yet the point is that whenever we design anything, we are making decisions that manipulate. We can either use that to drive a bigger profit, deliberately attempt to not manipulate (which may in turn unintentionally drive certain choices anyway), or use it to drive positive behaviour. “Structuring choice sometimes means helping people to learn, so they can later make better choices on their own,” say Thaler and Sunstein.

If we also implemented some of the ideas surrounding salad bars at these locations, we should also consider the idea of feedback. As any systems designer knows, feedback is critical to any user experience. If you gave pupils regular feedback about how their uptake of healthy options compared with the average, and crucially combined it with some visual feedback such as a happy (when eating healthier than the norm ) or unhappy (when eating more unhealthy) emoticon, the chances are that they would begin to increase their uptake. The visual feedback stops there being a boomerang effect for those who are eating healthier than the norm – i.e. it prevents them from drifting back towards the norm and makes the positive choice more sustainable. Experiments with energy users in California have shown significant success with this method.

Sometimes, the smallest, most inconsequential things can make a difference. Research shows that when you eat with one other person, you eat 35% more food than you would if you ate alone. When with three other people, you eat 75% more. With seven or more people, you may eat up to 96% more. Now consider the normal school dining hall, designed for hundreds of people to eat at once, often in large groupings. Perhaps even the very fact that dining tables are designed for large groups contributes towards them eating more!

Many schools design the way they run and their eventual environments around their own needs, to get a very large number of learners fed very quickly. Hungry or not, the school lunch time is often fixed and set, centrally, by the school. Within an hour – or sometimes less – secondary schools try to feed a vast number of people. They have little time to make a choice: they grab their food, pay, eat and leave. Observing such an event often reminds you of a military operation. Schools have large numbers of staff patrolling, letting in lines of students grouped by their age, walkie-talkies out. This is not a healthy environment.

Instead, we could consider designing around a people centred model. What is our vision of the experience we want to create? Probably one where learners eat when they are hungry, where they have choice about where they eat and what they eat, where time is not pressured, where queues are short, where the dining space feels vibrant and relaxing, where they can talk to their friends.

There may be a number of strategies for realising this vision. One could be to start to give learners more control over their own time within a school. In schools where learning is moving away from a centrally constructed experience to one co-constructed with learners, where learners spend greater amounts of time working in the same location instead of moving around, department to department, every hour, this becomes easier to manage.

This could result in distributing dining space instead of creating one central space. This allows more choice and variety, as well as creating less queuing bottlenecks and therefore more time for choosing and eating.

In summary: we should design our schools, systems and spaces around the type of experiences we want to create, not around the best way of controlling a necessary activity, supporting users in making choices that allow them to learn how to make better choices on their own.

Interlude: Obesity is socially contagious

As a brief interlude, we know that we cannot just think about individuals when tackling the problem of obesity. Research has shown that obesity is contagious in social networks. Most interesting is that the most powerful contagion happens in same sex friendship networks: more powerful even than amongst families. If a person you consider a friend becomes obese, your own chances of becoming obese go up 57 percent. Among mutual friends, the effect is even stronger, with chances increasing 171 percent.

Happily, the opposite is also true: thinness is also contagious. Of course, this is where issues like bulimia and other eating disorders can cause problems.

At the moment, experts are predicting that the tipping point will be towards the obese end of the spectrum, and that by 2050 over 80% of the UK adult population will be obese unless interventions are made now.

The point? Firstly, that helping even one person to lose weight can affect a greater number of people than you might immediately imagine. But more so, encouraging a healthy lifestyle and interest in eating well and getting exercise – as a matter of personal choice – will reap rewards through networks of young people. The effects of one person becoming obese, or thin, can extend out to three degrees of separation.

A key part of encouraging that choice is to find opportunities for helping young people choose to do more exercise.

How we can begin to personalise the sports experience

The problem with exercise for exercise’s sake is that it is a case of paying the costs now (in terms of both mental and physical effort), whilst getting the benefits later. So, we tend to find ways to reduce the “cost” now: usually through doing sports that we enjoy, or by competition.

Most sports in school take place with little choice of what you do, when you do it, or where you do it, and are usually designed with teams and competition in mind. Competition is a very powerful force, yet sometimes it is overlooked that a bigger motivation in the uptake of sports can stem from what psychologists call “perceived competence”. In short, the better you think you are at a sport, the higher the quantity and intensity of your take up of that sport both in school and out of school will be.

Our problem, of course, is not with those who perceive themselves as competent, but with those who perceive themselves as incompetent. We are well aware that there can be a vicious circle here: an overweight child gets picked last in an informal football game, they resent the humiliation and do not enjoy the sport, their self confidence decreases, which in turn could lower their sense of control over their own destiny, which often leads to more weight issues.

Let us consider a more people centred approach. Firstly, how can we engage every child in wanting to do physical activity? First on the agenda would be to look at the kind of experience we want to create by working with the children themselves. In fact, there is evidence to suggest that merely involving children in designing their own sports programmes increases uptake of activity. We would probably look at how we can help them have more choice over when they do sports, what sports they do, and where they do sports.

It may also mean that we stop presuming that a four court sports hall, designed primarily to support badminton, is the panacea for all school sports facilities. In fact, we may be able to create much more interesting and agile environments, depending on the type of experience we want to create and the activities we want to focus on.

It also may rethink our approach to competition. One strategy is to support learners in choosing sports that are about personal competition rather than group competition, supporting them and mentoring them much as an adult may have a personal trainer at a gym.

The gym is a good starting point, for those above the age of 17. Many schools do not have the funds to build excellent fitness studios, and those that are built can be small and inadequate. It is often the case that adult facilities such as a local LA fitness may be on hand minutes away from the school, which during mid morning and mid afternoon will experience very low levels of take up. We have yet to see a school strike a deal to lease an adult fitness space on a consistent basis, but we believe it could be turned into a win-win situation for both the school and the gym.

Gyms are often misused even by adults, who may view any kind of activity as an opportunity to eat one more muffin later, misguided by the calorie counter on the stair walking machine. Yet proper resistance based exercises, i.e. weights, are critical for developing the type of muscles that will increase metabolism and lead to more weight loss than other types of activities, as well as developing better posture and less injuries in the long term. Gyms complement other sports, but to get the most out of them, they often have to be combined with some degree of training. Without this, users tend to perform exercises badly, potentially causing more damage than good. So to properly introduce schoolchildren to gyms, we should not just let people loose but complement it with formal training.

Taking this to a whole new level is a concept I have been following closely and believe will be truly world changing. UR WLD is a new enterprise by Unvisited World, aiming to create a groundbreaking leisure experience for young people. It uses a concept I think of as personalised exercise, focussing on bringing together sports such as scuba diving, surfing, archery, martial arts, climbing, and even sky diving under one roof.

Its users will participate in the various activities, assisted by highly trained staff, and then be able to login to a personal portal collating feedback from a RFID enabled wristband which can support personal goal setting, and advise on exercises needed to improve at activities it knows they have spent longest at, such as archery. This gives the users the feedback which, as we noted earlier, is so critical to engaging them in sustainable choices.

All of this in an environment desired to inspire, excite, and explore.

And in truth, if we really want to tackle childhood obesity, that is what we have to do: inspire, excite, promote exploration and help people want to live healthy lifestyles. Define the experience we want to create, then create the right healthy environment to support that.