In Sunday’s New York Times, the editors ask prominent economists to weigh in on how to face the economic challenges ahead of us in 2012. Richard Thaler, of the University of Chicago, who wrote (with Cass Sunstein) Nudge, the best selling book on behavioral economics argues that employers have the opportunity to tackle one of our biggest challenges, health care spending. Employers are choice architects – they can make changes in how choices are offered that make one choice easier, or the default. Thaler argues that by making a few changes, employers can improve workers’ health, leading to greater productivity, fewer sick days, and lower insurance costs.
First, Thaler argues, make eating at work easier, by prominently featuring a variety of healthy options and putting in an attractive salad bar before the burger line. How might this look in real life? Let me use the cafeteria at my office as an example.
There are at least four cafeterias on our hospital/medical school campus and they aren’t all run by the same people, so the situation likely looks different on the other side of campus, but this is what it looks like in the cafeteria that sits right under my office and nearest the cancer center. The first thing you see when you walk in, is the grill/fry-o-later area. Serving up burgers, hot dogs, fries and onion rings, it invariably has a long line, which makes it easy to miss that there is a sandwich counter immediately to your left. The sandwich counter is hidden behind a high wall and camouflaged further by shelves of chips and candy, so unlike in many sandwich shops, you can’t see the choices. You can see two featured sandwiches. Sometimes one is healthy, but not always. Just past the sandwiches (and around the candy display) is the hot meal counter, which features one Weight Watchers entree each day. This may reflect my own food preferences, but I rarely find this entree to look very appetizing or particularly healthy (I realize “healthy” can have lots of different meanings, but something high in cheese and refined grains rarely meets my metric). To the far right of the sandwich bar is the pizza station, which usually features 3-5 types of pizza (most laden with meat) and another cheesy doughy option, like calzone, daily. Across from the sandwich bar is the featured entree special of the day. The days I’ve visited in recent memory this has been: nachos loaded with ground beef and processed cheese of the orange variety ( which I confess to finding appealing on Super Bowl Sunday, but I’m not kidding myself about it fitting in the healthy realm and I accept the health consequences of my choice), and beef stir fry laden with sauce of the kind women’s magazines regularly tell readers to avoid choosing when dining out, roast beef covered with gravy and accompanied by mashed potatoes. Just past the featured entree is the salad bar. I think most cafeterias these days have a salad bar, but having a salad bar and having an “attractive” salad bar are not the same thing. To their credit, since I started at my office nearly 5 years ago, the cafeteria has added mixed greens and baby spinach as daily options, offering something other than the white-ish iceberg lettuce of the early days. And there are proteins in the salad bar choices – typically hardboiled eggs, one type of canned bean and diced turkey or tuna. But the salad bar is a long way from what I’ve seen else where and a long way from allowing you to create the kind of salad you might get down the street at one of the neighborhood sandwich shops. Dried fruit? Nope. Other kinds of fruit? It is on the other side and is charged at a different rate. Nuts? No, but there are sunflower seeds. Cheese? Yes, there is usually grated orange cheese. I give the cafeteria credit, I can definitely create a greek salad for myself that rivals that fancy sandwich shop on the corner (with the possible exception of the tomatoes that always look a bit iffy) at a fraction of the cost. But it doesn’t look “attractive” and I’ve got to do all the work, which perhaps explains why there is never a line at the salad bar and I am 10 times more likely to see the people in front of and behind me at the checkout with fried chicken than a salad. This, I think, gets to the fundamental point – if you want people to make the healthy choice you have to make it easy and attractive. 
What about Thaler’s other suggestions? His second is making exercise easier. The health benefits of exercise, as we have said many times on CNiC, don’t require marathon duration or rigor. Walking is enough. And many employers subsidize gym memberships or arrange discounts, including mine. But you shouldn’t have to leave work to get a little walk in – making stairwells attractive is one way and the suggestion Thaler focuses on. In our conglomerate of old and new buildings, my workplace has lots of unattractive stairwells that are often hard to find. At a previous job, I had the privilege of sitting on a committee that was thinking about how to design a new hospital building and one of the most compelling ideas I heard was to make the stairwells front and center – highly visible and the easiest choice (instead of pushed off into the corner and behind a heavy metal door). One of our newest buildings on campus, which also serves as the home to our outpatient cancer care, has a lovely open stairwell at one end of the building, easily visible from the entrance. I enjoy seeing staff using the stairs and leaving the elevators to our patients, many of whom aren’t well enough to climb the stairs to the upper floors of the building. As we embark on a series of renovations and construction of new facilities as part of the 10 year plan, I look forward to seeing how our leadership makes stair use an easy option. In addition, our campus has launched a series of paths around the area (affectionately called “Tread the Med”) to allow staff and visitors to take walking breaks or have walking meetings (as Thaler plans to do in 2012). We have often used these exact “paths” around campus for our walking interventions during inclement weather and they are a great resource. I applaud the leaders who thought to leverage the bridges and hallways that link our conglomerate of old buildings as a means to promoting activity! Combined with easily located, accessible and attractive stairways, our step counts on campus should continue to rise.
Since most Americans spend more waking hours at work than at home, the role of our employers and workplaces at making healthy choices easy (or at least easier) can’t be underestimated. As part of our new TREC @ WUSTL center, our colleagues are examining just this – workplace policies that impact obesity, diet and physical activity.