Ulterior motivation

The power of serendipitously healthy habits

In the late 1990s, The Culinary Institute of America got a call from managers at a national chain restaurant who wanted help making some menu items healthier. A team of the institute’s chefs devised new versions of the recipes. The results were delicious. The restaurant leaders wanted customers to know.

“They were proud of what they were doing and wanted to put a ‘healthy’ icon next to those dishes on the menu,” recalls Greg Drescher, now the institute’s vice president of strategic initiatives and industry leadership. “We strongly advised against that; we said, ‘Change the recipes, put the new items on the menu, but don’t say anything about health.’ They said, ‘No, we want to help our customers find those healthy items.’ ” What unfolded next was an accidental experiment in human behavior.

The icon wasn’t ready when the recipes were, so the new dishes were put on the menu without it. Customers loved them. Eventually, the menus were reprinted to incorporate the icon. Now the customers could see which items were healthiest.

“Almost all those dishes tanked,” Drescher says. “From the consumer perspective it was like saying, ‘Thank you for pointing out the dishes I should avoid.’" Drescher’s story illustrates a health paradox: Although many of us believe we should eat better and exercise more, we may resist so-called healthy choices. Or we may try to make them, feel like we’re failing and give up.

The paradox is a big obstacle to solving the national obesity epidemic. To get around it, two Stanford nutrition scientists are shifting their focus away from asking people to diet or exercise for health reasons. Instead, they’re running scientific studies that tap our existing motivations to change, such as the pleasure we get in trying a tasty new food or the sense of purposefulness we derive from joining a large social or cultural movement.

“When people make a big change in their diets, it’s often because of an ‘aha’ moment, almost a religious experience,” says nutrition scientist Christopher Gardner, PhD, professor of medicine at the Stanford Prevention Research Center. “People may say, ‘I want to be a good citizen of the planet,’ or ‘I’m contributing to a broken social food system and I want to be part of the solution.’ They need an ‘aha’ moment connected to something much bigger than them.”

“So we’re asking, ‘Does a health-behavior-change intervention need to look, smell, feel, sound and taste like health education?’ ” says childhood obesity expert Thomas Robinson, MD, professor of pediatrics and of medicine at the School of Medicine. “Or can you intervene to improve health for reasons that are totally unrelated?”

The evidence that Robinson and Gardner are gathering suggests they can succeed with an approach they sometimes call “stealth health.”
Stealth-health research isn’t about sneaking carrots into the spaghetti sauce. “It is not deceptive; we’re not keeping anything from participants in our studies,” Robinson says. “Instead, we’re thinking about what is most motivating to them and having them pursue those goals, with better health tagging along as a side effect.”

Part of the movement

Robinson has spent decades studying traditional obesity-prevention and weight-management programs for children and families. But his curiosity about motivation goes back further, to a curiosity he noticed as a Stanford undergraduate in the early 1980s.

“Students would demonstrate and march against South African apartheid, but I didn’t see them going to East Palo Alto to teach kids to read,” says Robinson, who is the Irving Schulman, MD, Endowed Professor in Child Health. Why was discrimination halfway around the world more motivating than struggling kids next door?

“If you are trying to change the world by marching to end apartheid, or tackling a problem like climate change, even if you don’t succeed in the short term — and generally you don’t — you succeed in being part of the movement,” Robinson says. “But if you tutor a kid and it doesn’t work out so well, you are really setting yourself up for a failure experience.”

He believes the traditional approach to weight loss is similar. “If you don’t lose weight, it’s a very immediate failure experience, right in your face. It affects your confidence that you can make changes.” Robinson and Gardner want to circumvent this sense of failure.

Robinson’s first foray into the science of using motivation to set kids up for success targeted the TV. In a series of studies, the televisions of participating families were outfitted with an electronic device to track children’s screen time. Kids in his studies focused on all the things they could do instead of watching TV, participated in cooperative and competitive activities to reduce their screen time, and received social recognition at school and praise from their parents for cutting back their TV viewing. The activities worked: In studies lasting up to two years, children reduced their sedentary behavior, ate fewer calories and gained less weight than children in a control group.

Next, Robinson and his team designed after-school dance programs for girls at risk for obesity, focusing the curriculum on fun and cultural pride. African-American girls learned historical African dances, as well as contemporary hip-hop and step dancing, while girls of Mexican ancestry learned ballet folklorico, a form of traditional Mexican dance.

The girls got excited about learning new choreography, wearing colorful costumes and performing at community events. Their families — in impoverished neighborhoods where it’s hard to get a decent turnout at back-to-school night — showed great enthusiasm, too. “On a rainy Friday night in the middle of Oakland, we would average three family members in the audience for each girl performing,” Robinson says. “That would include parents, the older brother who could have been out with his friends, the grandma in a wheelchair from diabetes. It was really remarkable.” Compared with a health-education program given to a control group, the dance classes had larger positive effects on girls’ cholesterol, insulin levels and depressive symptoms, and showed some signs of slowing obesity. In the study of African-​American girls, after two years, the prediabetes rate was only about one-third of that observed in girls receiving the control treatment of health education.

These successes led Robinson to think more about what motivates school-age kids. His interventions are influenced by the work of Albert Bandura, PhD, a Stanford professor emeritus of psychology who recently received the National Medal of Science for his career studying human motivation.

“Kids love learning new things, they’re very social, they love being experts, they like being able to exert independence and develop their own identities,” Robinson says. And kids’ motivations can infect their families. “Parents’ lives are really crazy, but if your children have something they want to do and they pull you in, it pops up on your priority list.”

Recently, Robinson and his colleagues tested the impact of environmental sustainability programs on behavior change with Girl Scouts in the Bay Area. Children have the greatest stake in preserving the environment for the future and are often excited to help with sustainability efforts, Robinson says. And some behaviors, like walking and biking instead of driving, or eating less meat, fast food and highly processed and packaged foods, are beneficial for both the environment and for health. A recent study testing a five-session curriculum for Scouts and their families, published in Nature Energy in July, showed that girls increased their own conservation behaviors and got their parents to save fossil-fuel energy around the house by making changes such as turning off power strips at night, adjusting the temperature of the refrigerator and washing clothes in cold water. But when it came to eating less meat or walking to school, it was harder for kids to move their families’ dial. Although the girls changed their eating and transportation behaviors, the effects were not as large and did not extend to their parents.

The mixed results highlight a pitfall of the “stealth health” approach: Behavior changes aiming to achieve a goal other than health improvement — say, environmental protection — may not produce large enough effects to show a measurable impact on an individual’s health. The good news is that health improvement programs at any scale — from improving an individual’s diet to funding construction of new sidewalks to passing a soda tax — can be strengthened by planning with motivation in mind, Robinson says.

Robinson is now folding his motivational techniques into traditional studies of health-behavior change, too. A treatment program he’s testing for overweight Latino kids teaches them to exercise more, reduce their screen time, and eat smaller portion sizes. But instead of talking only about health benefits, the trial’s messages are designed to resonate with participants’ shared experiences as Latinos, such as enjoying traditional foods, critically evaluating the way the media represents their culture and receiving social support from their community. Kids in the study play on sports teams that emphasize fun over winning and don’t make them feel out of place for being overweight. And parents and coaches learn to use praise, constructive criticism and rewards to help motivate their children to stick with the recommended diet and activity changes. These studies are ongoing.

Row, row, row your … vegetables?

Stanford varsity rower Meredith Fischer didn’t expect a single college class to upend what she ate. Her dietary habits were entwined with her identity: A childhood nickname, Meef, which began as her little brother’s attempt to say “Meredith,” stuck because it rhymed with beef, which she loved. Once, in high school, she’d had a whole slab of baby back ribs in a single sitting, right before her team rowed a national-championship final. They won.

Then, in the winter of 2015, during her junior year, she took Robinson and Gardner’s Food and Society class.

“I was the biggest carnivore in the world before I took that class,” Fischer says. “I never, ever would have considered being vegetarian.”

Fischer didn’t realize that Robinson and Gardner designed the class with students’ motivations in mind. “We want them to explore their deeper values,” Robinson says, noting college students are developmentally ready to evaluate their beliefs. Food and Society students lead class sessions for one another to consider difficult questions: Are agricultural subsidies and food assistance programs appropriately designed, given that they may influence which crops are grown or which foods people purchase? Should you buy organic? How do your cultural values impact what you eat? What are the ethical and labor implications of eating fast food?

“We live in a world in which there’s a lot of uncertainty, so we ask students, ‘How are you going to behave in that context in a way that you feel good about?’ ” Robinson says. “We want them to struggle with making decisions when they don’t have professors giving them all the answers.”

Fischer did. She was worried about California’s extreme drought, and after a class discussion of the carbon emitted and water used in livestock production, she wondered out loud to a friend if she could eat vegetarian for a week. Her friend said, “There’s no way, Meef. I’d literally give you until dinnertime.”

The dare was impossible to resist. “It was hard at first; I was really hungry,” Fischer says. “But I also like to challenge myself. I wanted to prove people wrong.”

The health benefits of Fischer’s new diet have become a reason to stick with it. ‘But health alone wouldn’t have been an incentive for me to start.’

Once she figured out what she should eat instead of meat, her new diet got easier. Her coach — initially alarmed by her sudden vegetarianism — calmed down after Fischer got advice from a nutritionist in Stanford’s athletics department. Her performance on the water didn’t suffer. To her surprise, Fischer realized she wanted to stay vegetarian.

In the year since she first took her vegetarian dare, Fischer has learned that meat consumption is associated with greater risks for cancer and heart disease. The health benefits of her new diet have become a reason to stick with it. “But health alone wouldn’t have been an incentive for me to start,” she says.

Fischer’s experience in the class isn’t an isolated example; Robinson and Gardner published a 2010 study of the first cohort of their Food and Society students that showed significant improvements in students’ diets when compared with the diets of students taking other nutrition-related classes: more vegetable and less high-fat dairy consumption, as well as some signs that students reduced their intake of sweets and high-fat meats.

“It was a big surprise,” Gardner says. “We never talked to the students about health.” At the end of the term, he had asked students which topics left the biggest impression on them, thinking maybe the course materials could be winnowed down. An assignment about animal agriculture had caused one student to stop eating meat. A second student, raised on a ranch, said he knew food animals could be raised ethically, but that the class discussion on agricultural contributions to global warming had prompted him to eat smaller amounts of higher-quality, grass-fed beef. A third student was troubled by the business practices of fast-food franchises and had stopped eating fast food. So it went around the room.

“It was my epiphany, seeing that no one topic resonated with everyone,” Gardner says. After 20 years of trying to get research participants to eat better for health reasons, he was thoroughly convinced that he should try to get people to eat better for their own reasons. Today, Gardner and Robinson are testing the Food and Society class in a community-​college setting to see if the format will succeed beyond Stanford.

This raises a larger question: If framing healthy behaviors around people’s own motivations is so effective, why hadn’t it been tried sooner? Robinson thinks it may be because scientists have been reluctant to look at their own motivations. “One limit in public health is that we want people to do things for the ‘right’ reasons,” he says. “But we know that’s not how people behave.”

Accounting for taste

Today, Gardner is working with The Culinary Institute of America’s Drescher on a new stealth-health target: food cooked by the pros.
“We have some great data that show that more than 50 percent of Americans’ food budgets is spent on items designed by chefs,” Gardner says. That includes grocery-store items such as frozen dinners and deli-counter dishes, as well as restaurant food. Often, it isn’t as healthy as it could be.

“It’s regular or unleaded: Here’s a piece of steak or half a chicken, or over here are our vegetarian items,” Drescher says. This pattern leaves customers feeling forced to choose between healthy and tasty, and, as his anecdote about the failed menu icon illustrates, diners know which they’d rather have. So Drescher wants to scratch out the dividing line altogether. Healthy food should be “unapologetically delicious,” he says. Behind the scenes, he’s working to convince chefs that unapologetically delicious foods can simultaneously be nutritious, environmentally friendly and profitable.

In 2012, Drescher launched the Menus of Change initiative with scientists at Harvard’s T.H. Chan School of Public Health, one of several collaborations they’ve conducted to bring meals supported by nutrition science to commercial kitchens. And last year, Gardner and Drescher expanded the effort with the Menus of Change University Research Collaborative, led by Stanford and the culinary institute, which is asking scientists, chefs and administrators on 37 college and university campuses to advance healthy, delicious, plant-based menus in their cafeterias and to prompt more food research. They’re collecting data on how effectively chefs make changes such as reducing meat served and decreasing food waste, and are working to expand the effort to food served in other settings, such as at large workplaces (Google is getting involved) and hospitals. The larger goal is to test how to improve what people eat in these places, while simultaneously helping college students feel like healthy eating is the norm.

Menus of Change includes two important pieces of advice that relate to motivation: “Lead with menu messaging around flavor” and “Celebrate cultural diversity and discovery.” Menus should tell the right stories about healthy items; it’s not a matter of disguising what’s in a dish, but rather of talking about it in a way that will appeal primarily to customers’ taste instead of scolding them into doing what’s good for them. “A great majority of Americans are way more open to culinary adventure than they once were,” Drescher says. Chefs can take advantage by presenting their creations as mini-vacations to interesting locales.

One healthy-cooking technique the collaborators are studying, dubbed “the flip,” changes what’s at the center of the plate. It seeks a middle ground between huge, ​carnivore-​sating portions of meat and none at all. “We can say, ‘But it’s not vegetarian! This salad has steak in it; it’s global cuisine; we’re going for flavor profile,’ ” Gardner says. Behind the scenes, the health justification for the change is grounded by epidemi­ological data linking high consumption of red meat and processed meat with obesity, Type 2 diabetes, cardiovascular disease and some forms of cancer, as well as evidence that diets high in vegetables and fruits protect against several chronic diseases.

To help convince chefs that the “protein flip” would work, Drescher and his team collected data on what happened when they replaced some meat in hamburger patties with ground sautéed mushrooms. “We started to make prototypes and said, wow, this is really good,” Drescher says. He enlisted a food science team at the University of California-Davis to analyze whether the flavor stood up to traditional all-beef mixtures. The results, published in the Journal of Food Science in 2014, were convincing: Adding mushrooms boosts flavor with less sodium, less fat and fewer calories. It solves other problems, too.

“In volume food service, you can’t serve medium-rare hamburgers because of food-safety concerns, so the protein dries out,” Drescher says. “The mushroom hydrates it, plus you get this umami factor that’s not as present otherwise.” Umami is the savory “fifth taste” (in addition to sweet, salty, bitter and sour) that is abundant in foods like soy sauce and ripe tomatoes; it’s part of what makes a burger delicious. The data have already convinced some huge food-service companies to buy less meat. London-based Compass, which has a $14 billion North American operation, reduced red meat purchases by 10 percent in the fall of 2015, the first year that it began following Menus of Change principles.

Stealth-health yourself

Today, motivation-focused health interventions are moving outside labs and restaurant kitchens. On the “stealth exercise” front, there’s GirlTrek, a nonprofit that encourages African-American women to form groups in their neighborhoods for daily walks. “This is not a fitness organization, this is a campaign for healing. … We walk to heal our bodies, inspire our families and to reclaim the streets of our neighborhoods,” the organization’s mission statement reads in part. So far, 67,000 women and girls have pledged to walk regularly in their neighborhoods.

Robinson and Gardner have even snuck stealth-health elements into their own lives. Gardner leads a weekly volleyball game at the medical school that’s been going since 2001. Yes, it’s exercise, he says, but the players are mostly there to have fun. (The net they use was purchased with “employee morale” funds from the prevention research center.)

As for Robinson, after moving to San Francisco, he started taking public transportation and joined Stanford’s Commute Club, which gives financial incentives to employees who reduce their car trips to campus. He’s not quite sure what motivated him — maybe the money he saved, maybe the environmental benefits, maybe the fact that he really hated being stuck in his car. One thing’s for sure, though, Robinson says: “I don’t take the train for my health. But as a side effect, I noticed that after I stopped driving, my HDL went up by 10 points.” He attributes at least part of the rise in his “good cholesterol” to his daily walks to and from the train, which provide a stealthy bit of exercise he wouldn’t otherwise get. “That,” he says, “is pretty cool.”

Erin Digitale is the pediatrics science writer for the medical school’s Office of Communication & Public Affairs. Email her at digitale@stanford.edu.

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