Field Studies of Healthy Eating Interventions in …...Marketers / Retailers-avoid regulation -avoid bad PR-long term – can this continue?-short term – need healthy consumers Lots

9/16/2012

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Jason Riis, Harvard Business School

Field Studies of Healthy Eating Interventions in Retail Settings

Copyright © President & Fellows of Harvard College.

Obesity and associated diseases

Obesity – very prevalent

Diabetes – rates are rising

Cost – very high

Cause – eating too many calories

Minorities – particularly susceptible

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Stakeholders in obesity/diabetes trends: Incentives aligned?

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Healthcare Payers

~$2000/obese patient

(additional healthcare cost)

Policy Makers

-public health

-national competitiveness

-not just U.S.

Employers

~$500/obese employee

(productivity loss)

Consumers

-want to lose weight (health, cost, beauty)

-know they overeat

-rising healthcare costs

Marketers / Retailers

-avoid regulation

-avoid bad PR

-long term – can this continue?

-short term – need healthy consumers

Lots of work on consumer biases and overeating

• Wansink et al (2005) – Bottomless Soup Bowl

• Wansink & Chandon (2006) – Low-fat labels lead to overconsumption

• Chernev & Gal (2010) – Averaging bias

• …

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What can retailers / policy makers do?

• Price (taxes / subsidies)

• Information (raw)

• “Strong Nudge”• Awareness of nudge• Aligned with existing goal• Directive (but not too directive)• Immediately Actionable

• Change Defaults

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Triggers self control?

By-passes self control

Two strong nudges


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1. Invitation to downsize

2. Traffic light labels

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Pilot study: Attitudes to portions

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How big are the portions at the restaurants you typically visit? (N=142)

Usually too small

4%

Usually about right

59%

Usually too large

37%

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At the restaurants you go to, how often do you specifically request a smaller portion than is offered on the menu? (N=81)

Almost never

89%

Often

10%

Most of the time

1%

If the restaurants you go to started offering optional “downsized” portions at a very small discount, how often would you accept? (N=61)

Almost never

38%

Often

51%

Most of the time

11%


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At the restaurants you go to, how often do you specifically request a smaller portion than is offered on the menu? (N=81)

Almost never

89%

Often

10%

Most of the time

1%

How would you react if you were offered a “downsized” portion at a very small discount? (N=81)

Feel obliged to accept

7%

Happily accept

42%

Not accept

46%

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If the restaurants you go to started offering optional “downsized” portions at a very small discount, how often would you accept? (N=61)

Almost never

38%

Often

51%

Most of the time

11%

Why would you accept? (N=38)

To avoid eating too much

55%

To save money

24%

To avoid wasting food

21%

Three Studies at Panda Express: Questions

Study 1 Do customers spontaneously request smaller portions? Do customers accept nudges to take smaller portions for no discount or

for a nominal discount? If customers accept smaller portion nudges, do they compensate by

taking more calories in other parts of the meal?

Study 2 Are nudges more effective than calorie labels at reducing calorie

consumption?

Study 3 Do customers who take less food, actually eat less food? 12

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Ordering a meal at Panda Express

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Fried rice

Steamed rice

Chow mein

Mixedveggies

Orangechicken

Beijing beef

BBQ pork …

Mushrmchicken

Broccoli beef

Country tofu …

Step 2Order side dish

Step 3Order entrée(s)

Step 4Pay

$

Step 1Order meal size

How the nudge worked

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Fried rice

Steamed rice

Chow mein

Mixedveggies

Orangechicken

Beijing beef

BBQ pork …

Mushrmchicken

Broccoli beef

Country tofu …

Step 2Order side dish

Step 3Order entrée(s)

Step 4Pay

$

Step 1Order meal size

“Would you like to cut more than 200 calories from your meal by taking a half portion of your side dish?”

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Panda Express

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Panda Express

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Panda Express

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Orange chicken 440 calories

Beijing Beef 660 calories

Steamed Rice 420 calories

Study 1 Design – Summer 2009

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Sun Mon Tue Wed Thu Fri Sat

BASELINE BASELINE NUDGEno

discount

NUDGEno

discount

BASELINE BASELINE NUDGE25¢

discount

NUDGE25¢

discount

“Would you like to cut more than 200 calories from your meal (and save 25¢) by taking a half portion of your side dish?”

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Study 1 Customers – Summer 2009

• N = 283 receipts plus estimated gender and age• Exclusions:

• Group order• Partial meal order• Lost receipt• Ambiguous receipt

• 75% male• Median estimated age = 26

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Proportion taking half sized side dish portion

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discount

NUDGEno

discount


discount

NUDGE25¢

discount

1% 35%

4% 32%

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NUDGEno

discount

NUDGEno

discount

NUDGE25¢

discount

NUDGE25¢

discount

35%

32%

Calories per customer (Nudge condition only), n=164

464505

255

538

0

100

200

300

400

500

600

Side Dish Entrees

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Nudge Rejecters Nudge

Rejecters

Nudge Accepters

Nudge Accepters

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Calories per customer (Nudge condition only), n=164

464505

255

538

0

100

200

300

400

500

600

Side Dish Entrees

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Nudge Rejecters Nudge

Rejecters

Nudge Accepters

Nudge Accepters


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discount

NUDGEno

discount


discount

NUDGE25¢

discount

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Calories per customer, N=283

480

530

396

516

0

100

200

300

400

500

600

Side Dish Entrees

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BaselineBaseline

Nudge

Nudge

Calories per customer, N=283

480

530

396

516

0

100

200

300

400

500

600

Side Dish Entrees

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BaselineBaseline

Nudge

Nudge

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Paper 1 Conclusions

Study 1 Do customers spontaneously request smaller portions? NO Do customers accept nudges to take smaller portions for no discount or

for a nominal discount? YES If customers accept smaller portion nudges, do they compensate by

taking more calories in other parts of the meal? NO

Study 2 Are nudges more effective than calorie labels at reducing calorie

consumption? YES

Study 3 Do customers who take less food, actually eat less food? YES 27

Restaurants can help customers avoid overeating by providing self control nudges.

Strong Nudge … may not be needed over time

Introduce “right-sized” language With time, it could become part of fast food “script” Others customers may hear it

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March, 2012

Food Choices of Minority and Low-Income Employees: A Cafeteria Intervention

September, 2012

Strategies for solving self control problems

Pre-empt self control – the “Weak Nudge” Change default Choice architecture

Trigger self control – the “Strong Nudge” Awareness of nudge Aligned with existing goal Directive (but not too directive) Immediately Actionable

“Consume often”

“Consume less often”

“There’s a better choice in green or yellow”

TRAFFIC LIGHT LABELS

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Setting: Main cafeteria, Massachusetts General Hospital (MGH)

Over 6,000 employees and visitors visit the main cafeteria per day

Operated by the MGH Food and Nutrition Services

$30,000 revenue / day

Data: All register data for 9 months

~3 million items

PHASE 2: STRONG + WEAK

PHASE 1: STRONG

PHASE 0:BASELINE

Study Design and Timeline

December 1, 2009

March 1, 2010

June 1,2010

Sept 1,2010

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PHASE 1: STRONG


December 1, 2009

March 1, 2010

June 1,2010

Sept 1,2010

Phase 1: Labeling (RYG)

All food and beverages in the cafeteria were labeled as red, yellow, or green based on an algorithm we developed from USDA food pyramid guidelines

“Consume often”

“Consume less often”

“There’s a better choice in green or yellow”

Self control may kick in with regular reminders that you are choosing the unhealthy (red) item

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December 1, 2009

March 1, 2010

June 1,2010

Sept 1,2010

Phase 2: Labeling + Choice Architecture (CA)

• Implemented after Phase 1

• “Choice architecture” intervention • Make healthy foods (green) more convenient/visible• Make unhealthy foods (red) less convenient/visible

• Changes were made over a weekend and not advertised to cafeteria patrons

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Before ……………………………. and After Choice Architecture

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Choice Architecture: Water everywhere

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Data analysis

Calculated proportion of sales that were red, yellow, and green during each 3 month period (baseline, Phase 1, Phase 2)

Tested significance of relative change in 3-month sales of red and green items between phases Baseline - Phase 1 Phase 1 - Phase 2 Dependent variables: red or green items Independent variable: Phase Controlled for day of week

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Results 1 – Overall choice patterns

Excluded weekends and holidays (including Dec 24 – Jan 3)

Excluded “boil water” emergency (May 1 – May 5)

Salad bar purchases assigned Green (2/3 of items were green, 1/3 yellow)

~1 million items sold each period

~$30,000 revenue / day


PHASE 1: STRONG

PHASE 0:BASELINE


December 1, 2009

March 1, 2010

June 1,2010

Sept 1,2010

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Sales of all cafeteria items during baseline, Phase 1, and Phase 2

0

5

10

15

20

25

30

35

40

45

Red items Yellow items Green items

Baseline

Phase 1 (RYG)

Phase 2 (CA)

% o

f tot

al c

afet

eria

sal

es

Relative change in sales of red and green items in Phase 1 and Phase 2

PHASE 1 (RYG) PHASE 2 (CA)

Proportion of baseline sales

(N=977,793)

Relative change from baseline P value*

Relative change from

Phase 1 P value*

All red items 24.9% -9.2% <.001 -4.9% <.001

All green items 42.2% +4.5% <.001 -0.5% <.001

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Sales of cold beverages during baseline, Phase 1, and Phase 2

0

10

20

30

40

50

60

Red beverages

Yellowbeverages

Greenbeverages

Baseline

Phase 1 (RYG)

Phase 2 (CA)

% o

f tot

al b

ever

age

sale

s

Relative change in sales of red and green cold beverages in Phase 1 and Phase 2


Proportion of beverage sales at baseline(N=199,153)


Relative change

from

Phase 1 P value*

All red beverages

26.1% -16.5% <.001 -11.4% <.001

All greenbeverages

51.7% +9.6% <.001 +4.0% <.001

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Sales of bottled water and soda during baseline, Phase 1, and Phase 2

0

5

10

15

20

25

Water Diet soda Regular soda

Baseline

Phase 1 (RYG)

Phase 2 (CA)

% o

f all

cold

bev

erag

es

Relative change in sales of water and soda during Phase 1 and Phase 2


Proportion of beverage sales at baseline(N=199,513)


Relative change from

Phase 1 P value*

Water 13.6% -2.4% <.001 +25.8% <.001

Diet soda 19.6% +9.2% <.001 -0.8% <.001

Regular soda 19.5% -23.1% <.001 -5.9% <.001

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Comparison site analysis: PHASE 1 PHASE 2

Proportion of baseline sales

Absolute change from baseline

Between group difference

Absolute change from Phase 1

Between group difference

Red Chips

Intervention 36.7% -0.8% -3.9% -5.2% -11.2%

Comparison 77.4% +3.1% +6.1%

Red Sandwich

Intervention 14.6% +2.5% -0.3% -2.7% -0.7%

Comparison 10.3% +2.8% -2.0%

Green Sandwich

Intervention 24.0% +0.5% +1.9% +7.5% +4.3%

Comparison 20.2% -1.4% +3.2%

Bottled water

Intervention 13.6% -0.3% -1.1% +3.4% +3.2%

Comparison 18.6% +0.8% +0.3%

Results 2 – “Platinum Plate Users”

4,642 employees

73% white, 10% black, 7% Asian, 10% Latino

53,371 transactions during baseline

131,417 items during baseline

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Trends by Race

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02

04

06

08

01

00

pe

rce

nt

Black Latino Asian White

B L C B L C B L C B L C

B = Baseline, L = Labeling, C = Choice Architecture

Red Yellow Green

Intervention effects by race -- Overall purchases

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Baseline Phase 1 Phase 2

Red Purchases AverageRelative percent change

from baselineRelative percent

change from Phase 1Overall 20.9 -11.2 * -4.1 *White 19.3 -12.1 * -5.0 *Asian 21.3 -6.1 -7.1Latino 24.7 -11.4 * 3.7Black 29 -10.1 * -3.0

Green Purchases

Overall 45.4 6.6 * -1.9 *White 46.5 6.6 * -1.5 *Asian 46.9 3.9 -1.9Latino 43.1 9.4 * -5.2 *Black 37.6 6.7 * -2.4

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Intervention effects by race -- Beverage purchases

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Baseline Phase 1 Phase 2

Red Purchases AverageRelative percent

change from baselineRelative percent change

from Phase 1Overall 24 -23.8 * -14.2 *White 21.8 -25.6 * -17.1 *Asian 28.2 -17.1 * -18.1 *Latino 29.1 -23.3 * -3.3Black 33 -20.6 * -5.9

Green Purchases

Overall 59.3 5.6 * 2.3 *White 62.8 5.8 * 2.4 *Asian 51.4 5.4 0.5Latino 51.4 5.2 -0.9Black 47.2 3.8 5.8

Intervention effects on calories and price per beverage by subgroups

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Average calories (kcal) per

beverage at baseline

Change in calories (kcal) per beverage

from baseline to Phase 2

Average price per beverage at

baseline

Change in price per beverage

from baseline to Phase 2

Overall 95 -15 * $1.34 $0.00

White 87 -15 * $1.30 $0.02 *

Asian 112 -14 * $1.35 -$0.02

Latino 113 -12 * $1.42 -$0.04

Black 126 -17 * $1.42 -$0.04 *

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Conclusions

• Traffic light labels are an effective “strong nudge”

• Effectiveness increased in context of healthy choice architecture

• Particularly effective for beverages

• Effective with minority / lower income employees as well

• Could improve the reach and effectiveness of calorie labels

• Traffic light labeling: It’s not just product information

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Two strong nudges


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1. Invitation to downsize

2. Traffic light labels

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Closing thoughts

• Obesity is a marketing problem / retailing opportunity

• Strong nudges can work in retail settings and are feasible

• More field studies are needed

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END

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Documents

Field Studies of Healthy Eating Interventions in …...Marketers / Retailers-avoid regulation -avoid bad PR-long term – can this continue?-short term – need healthy consumers Lots