Nudge and Wellness

We've all heard the expression “An apple a day keeps the doctor away.” Well, I've got a question for you: What if it's true? Wouldn't that be easy to do—to eat an apple a day? Here's the problem: It's also easy not to do.

—Jim Rohn¹

Traditional corporate wellness programs have assumed that if employees only had information about healthy choices and received a $300 discount on their health insurance premium for achieving their modest goals, that would be enough to persuade them to change.

That hasn't worked and won't. That's because humans are not rational decision makers.

And that is why behavioral economics has become such an emergent force; it certainly formed a major part of our research for this book. Behavioral economics is built along the difference between our autopilot, intuitive side, and our more deliberate and reflective side. A nudge is often all it takes to make a good choice easier and a bad choice harder. Designed nudges can influence policy, programs, work design, workplace strategy, purchasing decisions, physical environments, social network effects, and other features of contemporary life. Nudges are much less intrusive (and expensive) than efforts aimed at changing people.

Daniel Kahneman, the cocreator of behavioral economics, spoke about this during a recent podcast: “Instead of asking, ‘How can I get him or her to do it?’ start with a question of, ‘Why isn't she doing it already?’ Very different question, ‘Why not?’ Then you go one by one systematically, and you ask, ‘What can I do to make it easier for that person to move?’”²

The Homer Simpson Effect

My associate Michael Lagocki and I drove out of Dallas very early one morning, headed for a 9 a.m. meeting at Texas A&M's School of Public Health. The first 90 minutes of our road trip down I-35 flew by so very quickly. But, when we took the exit to College Station at Waco, we ended up on a mostly two-lane highway. That's when we began to get stuck behind farm tractors, pickups, and big tractor-trailer rigs. Our conversation suddenly tapered off as I began to concentrate more on the road and my driving duties.

That is the first principle of behavioral economics. Our brains work in two modes. Autopilot, our default mode, is designed to conserve energy. It works about 80% of the time. That's why we can usually safely drive (a modern automatic function) and talk at the same time. But, our intentional, focused, reflective mode is necessary for high-demand times, like driving through downtown Chicago during rush hour.

For another trip, I flew to Holland, Michigan, to make a presentation at an event. Since I had to arrive the afternoon before the event and spend the night in downtown Holland, I walked through the beautiful April evening down to Butch's Dry Dock for dinner. As I walked, I firmly decided to order their healthier salmon Caesar salad. But I ran into some colleagues at Butch's; they asked me to join them for dinner. Now, I was absolutely committed to salmon Caesar, until I wasn't. Two of my colleagues said, “You've got to try the smoked pork!” And they didn't stop there: they described it in sensual detail. So I ordered the smoked pork, fully aware that I just abandoned the healthy choice I had been so determined to consume. The moment got worse: a round of appetizers; a nice local stout beer, possibly two; and a flaming, cascading, volcanic desert.

I got “Homered.” You must remember the forbidden donut—season 5, episode 5 of The Simpsons, “Treehouse of Horror IV.” Homer became so enamored with the donut that he sold his soul to the devil.³ The Homer Simpson Effect is what happens when your autopilot chooses the tangible and delicious now rather than the healthier, but too abstract you, way off in the fuzzy and distant future.

Our autopilot looks for shortcuts when we confront complicated, hard, ambiguous, or risky situations. Most of us don't read our insurance policies. That's because we're not rational beings. We've learned it's far better to look deeply into the insurance agent's eye and discern whether to trust her. Of course, we are smart enough to read and comprehend the policy, but we conduct a quick, instinctive, gut calculation comparing the pages of small font content against a set of cognitive biases and rules of thumb. In my case:

• Jerry recommended her—third-person credibility
• The company is a brand name—availability bias
• Pricing is comparable to competitors—confirmation bias

Insurance companies, banks, mortgage lenders, and software companies can certainly provide easy-to-read, plain English contracts that highlight the areas of most interest or concern. But they count on people like me, who will quickly scan a document and think, Do I really need to read all this legalese? I mean, nothing bad has happened so far (subjective validation bias), so I will take that as a sign for the future. But, the devil is in the details, and it is after my roof needs to be replaced that I learn we have rain and hail coverage, but that doesn't cover wind damage. What?

Predictably Irrational

We already know that we are irrational beings. But, we are predictably irrational.⁴ That is why supersizing works. And that's why checkout lines are filled with impulse items. Now, you know how Netflix has elegantly nudged us into binge watching. And, face it; you are simply not built to resist Aunt Martha's extra helping of apple pie. Our predictable irrationality is also why people smoke, even doctors who have the knowledge that cigarettes are killing them. They even smoke when they have financial incentives to quit.

Our predictable irrationality undermines efforts to introduce new programs, new technology, new compensation plans, and relocations—even when the new is much better than the old. But, because it is predictable, we can use it to help counteract irrational fears, shift from harmful to healthy behaviors, and embrace change.

Traditional economists start with the premise that humans are rational decision makers who optimize their gains and minimize losses. Behavioral economists start at a different point. As psychologist Dan Ariely explains, they begin by watching how people actually make decisions, and then reverse-engineer these observations, looking for common patterns. That difference in approach explains why traditional wellness programs have never been successful at changing human behavior.

Incentives, information, and willpower are no match for environmental triggers that only have to catch people off guard, as they did for me at the dinner in Holland.

Sirens in the Workplace

The classic story of the Sirens in Homer's Odyssey provides a splendid example of how to overcome irresistible temptation. As you probably remember from high school, the Sirens sang such beautiful and seductive songs that they lured ships to destruction and death on the rocky coast of their island. So, Ulysses ordered his crew to push wax into their ears to avoid yielding to the Sirens' songs. But he wanted to hear their songs, yet live to tell the story. So, he ordered the crew to lash him to the mast to prevent his steering the ship into the rocks.

Being tied to the mast is a commitment device, a tool to overcome the temptation that compromises long-term goals. Through behavioral economics, we can employ nudges and commitment devices to assist us in the higher, nobler, healthier, and more profitable patterns of life.

Bob had a 7:30 a.m. meeting at the office. So, after a late night, he chose to stay in bed until the last minute, skipping his wife's healthy breakfast. He knew coffee and some food would be waiting at the office. Sure enough, when he arrived, coffee, orange juice, and great and seductive pastries, pancakes, and biscuits and gravy were beautifully spread over a table. Most workplaces are littered with tempting Siren songs: they fill our bodies with sugar and empty calories. We don't seem to know or care that we're headed for the rocks.

The Power of Framing

Choices can be worded in a way that highlights the positive or negative aspects of the same decision, leading to changes in their relative attractiveness.⁵

Dr. Roizen discovered 20 years ago that his main job was motivating patients to live healthier. The traditional model armed him with compelling information about his patient's health risks. He could and did use scare tactics if necessary, but found they seldom worked. He learned that a person's habits and unhealthy social networks were more powerful than information, warnings, and pressure.

But, when his research uncovered six areas that could dramatically reduce risk and improve mortality, he reframed the conversation: How would you like to live 10 years younger? He calls this the empathetic future. It was a future that was imaginable because it brought new life to the realm of the possible.

Dr. Roizen's Real Age assessment is a great reframing device. It calculates chronological age against biological age. It is sobering and hopeful. When patients score poorly, he explains, “You are 55 but have the body of a 65-year-old.” Once that sinks in, he asks, “How would you like to feel like 45 again?” That is a powerful and effective conversation, especially when the patient holds the Real Age score and assessment in her hands. Dr. Roizen confirms the patient's current state, clarifies the stakes, and makes the better future tangible. He reframes the issue, and reframing engages the focused side of the brain. Removing the clutter allows the brain to stay engaged.

Why do people not do what serves their long-term best interest? If we can step into their shoes and observe their surroundings and the social habits, can we begin to reframe and redesign their environment to remove those constraints?

Reframing is a critical, but often overlooked, device for managing. When CBRE proposed to move all paper files to the cloud, that news brought anxiety, especially among the many “digital immigrant” brokers. Anticipating that anxiety early (a key to good nudge thinking), they hired digital coaches to help employees scan, tag, and learn how to retrieve their files. Because they did, the narrative quickly shifted from, “I'm losing years of files that are crucial to my work,” to “I'm a better broker today and can work from anyplace.”

Calvin Crowder, vice president of global real estate for GoDaddy, describes their challenge, in a previous building, to encourage employees to use the recreation area to take breaks and have fun with colleagues. Because of its back-of-the-building location, people felt like they were sneaking off to have fun. In their new Global Technology Center in Tempe, Arizona, Calvin placed the recreation area in a central and highly visible place. When our group convened there, we watched people playing table tennis, ascending a climbing wall, riding pedal go-carts, and simply hanging out. Placing a recreational break room in a central space took away the old stigma.

Freedom of Choice and the Battle for M&M's

During our Google summit, someone raised the question, “Are nudges inherently evil?” In other words, are they manipulative? Do they represent Big Brother? Can our companies and our local, state, and federal levels of government be trusted to nudge us in appropriate ways?

The short answer, at least for Google and their director of health and performance, Josh Glynn, was that, for example, the dining areas do not remove unhealthy food and drinks. They are simply less visible to the autopilot brain but in plain sight to the focused brain. In the microkitchen refrigerators, the top half of the glass refrigerator doors reveal healthy waters, coconut water, kombucha, etc. But, if you look at the bottom frosted-glass displays, you can see some blurred red, burgundy, and green cans that contain favorite sodas. The glass is just sufficiently opaque to slightly blur the branding cue of major soft drink labels.

Google's first employee, Craig Silverstein, reportedly created their early M&M's culture. I love peanut M&M's. If there is a bowl on the table, I will start with the very subtle thumb-and-two-finger grab, just a few; easing into a second and third swipe using all five fingers. One peanut M&M contains 10.3 calories. So, my 20 M&M's added 200 useless calories; 100 of those calories are fat. And, for me, 20 is just getting started.

In 2006, Google used regular (nonpeanut) M&M's, 3.4 calories each, for a seven-week experiment in their Midtown New York office. They placed the M&M's in an opaque jar among several clear jars of healthy nuts and dried fruit. That office of 2000 people consumed 911,765 fewer M&M's, 3.1 million fewer calories, and 885 fewer pounds.⁶

But, then, Google took note of the recurrent weight gain (averaging 15 pounds) of “Nooglers” (new Googlers). That became known as the Google 15. So, Google implemented several nudges on a path to improve choices, reduce food portions, and encourage physical activity. They seem to be working. I don't know if M&M's are really the Google snack of choice, but I like the project because it captures all the elements of an intervention aligned with Google's values: their willingness to experiment, learn, rigorously measure, remain transparent, and use feedback as reinforcement.

The Seven Pillars of Wisdom

Okay, here's the real essence, the secret sauce, the elixir, the Seven Pillars of Wisdom behind nudge thinking:

1. Default: Make the healthy choice the default option. Haworth's headquarters placed the elevators at both (and very distant) ends of a very long building core. But the centrally placed stairs provide a beautiful and panoramic view of the interior of the office and its exterior landscape. Taking the stairs is automatic, even desirable. I have been going to that headquarters since it was built in 2008 and didn't even know the elevators existed until recently.
2. Appealing: Give the nudge a solid appeal. The Haworth stairs invite you to climb. Four Winds Interactive wants everyone to pause for a few minutes each hour. So, at five minutes to the hour, all vertical display monitors rotate images of employees with their dogs. That brief happiness break has had the serendipitous effect of connecting employees to each other through their pets.
3. Intuitive: The City of Fort Worth painted a simple sign above the stairwell door in their elevator lobbies: StairWELL. That clear, intuitive prompt nudges everyone into thinking “Sure, why not?” As you leave the Four Winds Interactive office for lunch, the interactive monitor provides a map of the surrounding areas and highlights healthy restaurants and a round trip step count.
4. Simple: Less is more. Barry Schwartz's research found that two or three really good healthy choices are far better than a dozen options. When I'm at GoDaddy, I can go directly to the healthy food island, located very prominently in front of the area that serves pizza, burgers, and barbeque. Ergonomic chairs that provide a few easy adjustments work far better than those with highly complex chair adjustments. One ergonomic chair company that sold expensive chairs with multiple adjustments received many complaints about discomfort. They quickly discovered that very few users knew how to adjust the chairs.
5. Feedback: Giving people immediate positive feedback reinforces behavior. Receiving recognition on the cafeteria receipt for a healthy choice or getting a small discount on the next purchase signals “Good job!” The new Delos space in New York installed an interactive digital display in the stairwell. It responds to the number of times employees go up or down the stairs, but does so in a fun and artistic way. That interaction adds a gamification element.
6. Forgiving: Okay, I mess up; something will break, or I just didn't read the instructions. Does the system have airbags for these “oops” moments, or do I get penalized? My sister's Fitbit band broke. For the three days it took to replace it, she was unable to track her steps that counted toward their insurance discount. Because she could not make up the difference for the month, her company reduced their discount by 8%. The system provided no forgiveness despite calling to ask for help. Barry-Wehmiller's health concierge provides airbags for employees who run into problems with their medical providers, including billing issues.
7. Norms: Leaders produce the positive behaviors they desire by modeling, recognizing, measuring, and rewarding. The Cleveland Clinic measures five outcomes: (1) blood pressure, (2) BMI, (3) triglycerides, (4) LDL cholesterol, and (5) cotinine (an alkaloid found in tobacco). A family who meets all five metrics receives a $2,400 discount on their insurance. They give doctors who smoke six months of support to quit, or they are gone. Their program is the extreme. But, if measured in participation and cost savings, it is one of the most successful. Sixty-eight percent of their employees with chronic disease participate compared to less than 12% for most companies.

The Domino Effect

If you watch a very simple but brilliant YouTube video called “Domino Chain Reaction,” by professor Stephen Morris,⁷ you'll understand why it has over 2.5 million views. You will see 13 dominoes, ranging progressively larger from just 5 millimeters high up to the largest, at 1 meter high and about 100 pounds in weight. The first very small domino falls into the second one, releasing one small unit of energy. But when the largest one falls, it releases 2 billion units of energy.

And that is the secret of the domino strategy of progressively bigger nudges. It's the old cliché: “The larger they are, the harder they fall.” Each domino nudges the gravitational pull of the next larger domino.

When some people hear about nudge thinking, they ask, Why we don't just start at the top with leadership and culture? We don't because they are the biggest dominos. They are the hardest to budge; they need some well-designed momentum to shift their mindset and behavior.

Most wellness approaches try to get individuals to change instead of shifting the dynamics of the system. But think about the public health “dominoes”: public service announcements, news media warnings, Centers for Disease Control and Prevention reports, surgeon general's warnings, and other information strategies use the domino chain reaction strategies. They first alter the environment; that shifts choices, which leads to influencing behavior until it becomes habit, and that builds a societal norm. Habits eventually change our thinking. For some reason, the wellness world ignores effective chain reaction strategies and continues targeting individuals.

The Nudge of Norms

Norms create powerful social nudges. They encompass leadership, environment, and the shadow culture. Norms—the pattern or model of what is normal—impose the constraints that prevent the adoption of new policies, behaviors, programs, or new ideas.

Boomers and Gen Xers remember when casual Fridays were first introduced. Of course, that shocked some. We joined a great debate: “What if someone showed up in shorts?” But, once in place and with the rise of the dotcom industry during the 1990s, business casual became the norm. And then it was full casual (skating to the very edge of what was socially acceptable, or even legal) on Friday.

New norms provide powerful opportunities for shifting behavior. The most effective ones capitalize on inherent interests and work to strengthen and legitimize emerging ideas or trends. Google knows that people who feel connected to others are happier and tend to stay with the company. So, instead of starting a program called We Are Connected, they look for natural, organic groups and offer to provide structure and even training to help the tacit leaders strengthen the group.

Engagement with social norms, and an appreciation of their powerful influence on the well-being of populations, can be an important part of the work of public health [and the workplace—my addition], consistent with our emphasis on prevention, and our aspirations for healthier populations.

—Sandro Galea, MD, DrPH at Boston University

Betsy Price, the mayor of Fort Worth, Texas, told me about the new norms she has begun to introduce. Like the Walking School Bus, kids walking to school with an adult. It was developed to address growing child obesity. Because of that initiative, kids who normally get less than 30 minutes of exercise a week now walk 30 minutes a day and up to five miles a week.

Mayor Price also talked about her other initiatives. “We started our ‘Rolling Town Halls,’ on bicycles so that we could see different parts of the city and talk to people while we were cycling. We also have ‘Walking Town Halls’ on Saturday morning. We walk in different neighborhoods and different parks. We all soon realized that could be a big draw for businesses. If you've got a community that's beginning to take responsibility for their own health, that'll be a big draw and put us on the map and set us apart from other communities.”

She also explained the very important issue of pacing: “You need to pace your employees and communities, so it doesn't feel like it's a push. ‘“Take an extra 15 minutes and walk on your break.’” Or, ‘“We will put healthier choices in our cafeteria.’” Blue Zones, a holistic wellness program, tells people to eat a ‘“plant centered diet,’” mostly plants. But, this is Texas. This is beef country. So, we just try to make healthy choices a little easier. We just said to people, ‘“If you're used to having beef six days a week, think about having it three days or four. Think about adding in more fruits and vegetables. Think about taking your family to the park.’” That's why we're increasing our trail connections, increasing our parks so that they're available. They're close to everybody's home or everybody's business, and the closer you are to parks and to outdoor spaces, the more likely people are to use them.”

Fort Worth has adopted nudge thinking to remove barriers, improve choices, and invest in the environment that affects everyone. Mayor Price added, “Our goal of the city is to work on the built environment. We're working on making it easier for our employees to find a place to walk. And we've set up a lap counter in City Hall and encouraged the department heads to get up from their desks and do some standing meetings, and to get their staff out walking. We're in the process of changing some of our vending machines so that when you walk up to the vending machine, the first thing you see is the water. People will still have that choice of sodas, but they'll be higher or lower. Same thing with the healthy choices in the snack machines. Just very simple things. Our ‘Blue Zone parking’ spaces are a little further away from the building.”

So many of these ideas represent low-hanging fruit, not radical change. For example, did you know average dinner plates were 9 inches in diameter in 1900? And the average grew to 10 inches by 1950, and to 12 inches by 2010.⁸ Today, for obvious reasons, the 9-inch plates are coming back. They reduce portions by 30% but still look full. That, and other beautiful nudges like hiding M&M's or sodas behind frosted glass, are helping many to live healthier, safer, and more prosperous lives.

And that doesn't require spending great sums of money or devising severe or coercive measures to force change. Nudge thinking begins by asking “What's keeping someone from already doing the good thing?” The work begins by uncovering the various constraints and experimenting with one nudge after another to discover the tipping points of acceptance and adoption.