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Role of Industry and Consumer Perspectives

The speakers in the next session, moderated by Alison Brown, National Institutes of Health, began by reviewing the challenges consumers face in choosing healthy diets. Speakers then described varying industry perspectives on how to promote these healthy behaviors and actions being taken to facilitate that process, thus looking to the future for sustainability and next-generation programming.

NEUROPHYSIOLOGY OF CONSUMER CHOICE

Marco A. Palma, Texas A&M University, reviewed the neurophysiology of consumer food choice, beginning with an evolutionary biology trip back to the time when humans were hunters and gatherers and spent most of their energy securing food for survival. During that time, he explained, the brain provided rewards in ways that are similar to reward responses for highly addictive substances today. Now, he said, humans typically spend much less time foraging and securing food, making it relatively cheaper and easier to obtain; however, the brain’s evolution has not kept pace with advances in agriculture, and humans still live in a world that rewards them anatomically for finding and consuming sugar-dense food. When humans face these urges, he added, there is a connection between the reward system and the brain circuitry—particularly in the regions related to self-control—that determines enjoyment of food.

Palma went on to review evidence from neuroeconomics showing that the brain regions activated when people see words like “healthy eating” are different from those activated by more emotionally driven, hedonic

messages related to tasty food. But not everyone, he observed, experiences the same self-control urges. Palma referred to two predominant and seemingly contradictory theories proposed to explain self-control. One theory suggests that self-control is like a snowball: the more one engages in an activity, the more motivation is generated, and the greater is the likelihood of exerting self-control in the same or unrelated activities. The second theory says self-control is a finite resource, and once people have run out of it, they are unable to access and use it. Palma proposed, however, that these are not two different theories but parts of the same unified theory that are missing a compliance measure to link them. Essentially, he elaborated, the initial act of self-control enhances subsequent acts, but once self-control is overdone or drastic measures are taken, it becomes overwhelmingly difficult to continue to exercise restraint, and people can set themselves up to fail by trying to do too much (Palma et al., 2018).

As a closing example, Palma shared a study in which consumers were given wine to taste from two different bottles; the wine in both bottles was identical except for the price tag. Participants’ brain activity was then measured through functional magnetic resonance imaging. The researchers found that the medial orbitofrontal cortex, a region of the brain associated with pleasure, was activated more with the expensive bottle of wine than with the lower-priced bottle (Plassmann et al., 2008). Palma explained that this finding is crucial because it illustrates the importance of nonphysical attributes of foods and their critical role in determining how much pleasure consumers derive from eating them.

INSTACART

Beatrice Abiero, Instacart, discussed how the grocery technology company partners with more than 1,400 retailers across the United States and Canada to provide access to grocery delivery for more than 95 percent of households. Over the past decade, she said, Instacart has worked at the intersection of food and people, which also means it intersects with health, and the company is rethinking how it can become more of a health enablement platform. She reported that last year the company launched Instacart Health with the goal of expanding access to nutritious food and delivering healthy outcomes. She described the three pillars of the program: improving nutrition security, making healthy choices easier, and scaling food-as-medicine programs. Abiero highlighted Fresh Funds, which allows any entity, including hospitals or researchers, to produce category-restricted stipends and related food-as-medicine programs online. A second initiative is Virtual Storefronts, which allows entities to provide a branded, customized experience to show different dietary regimens.

Given Instacart’s technology and reach across the continent, Abiero continued, it is uniquely positioned for research opportunities and can provide infrastructure to programs. For example, Instacart partnered with the University of Kentucky and No Kid Hungry to conduct a study aimed at better understanding the impact of online groceries and their delivery for families on tight budgets. Following extensive analysis of receipts and survey data, Abiero reported, the study found that individuals were able to stretch their food budgets, decrease stigma, and save time when grocery shopping online. For those who shopped online and received additional guidance in navigating the online environment, an average increase of nearly $7 was spent on fruit and vegetable purchases. Abiero concluded by stating that collaborations will focus on empowering patients to navigate the food system with tools at their fingertips, integrating recipes, and supporting the American Heart Association’s Food Is Medicine initiative. These studies shape how Instacart centers the user experience, she explained, and she is excited to continue working with researchers to empower consumers to improve their health.

KELLOGG COMPANY

Sarah Ludmer, Kellogg Company, shared the company’s plan to give “better days” to 3 million people by the end of 2030 by approaching the goal in four intersecting ways: sustainability; well-being; hunger; and equity, diversity, and inclusion. Over the past 20 years, she said, Kellogg has focused on making food healthier by increasing such components as whole grains and fiber while also reducing “negative ingredients,” such as sodium and sugar. She argued, however, that a shift is needed in how to provide equitable food access more broadly and in how “nourishing” is defined. In 2016, for example, Kellogg petitioned the U.S. Food and Drug Administration (FDA) to increase the amount of vitamin D allowed in cereals. At the end of 2022, this request was approved, and all manufacturers can now offer increased vitamin D levels in their foods. Ludmer emphasized the importance of focusing on positive nutrients and on eating more healthy foods, saying that this focus can be more impactful than just avoiding the intake of unhealthy foods. She pointed to research showing that eating more healthy foods, such as whole grains, fruits, vegetables, and nuts, had a greater impact on overall mortality than did reducing the intake of unhealthy foods. She noted, however, that studies also have shown that high intakes of sodium have a direct impact on mortality, so she emphasized that it is important to think about the overall picture of health and diet.

According to Ludmer, cereal is a food that repeatedly plays a role in the intake of different nutrients for many Americans. She observed that cereal

eaters are typically found to have higher intakes of the shortfall nutrients (such as iron and folate) and higher overall scores on the Healthy Eating Index (Zhu et al., 2022); moreover, they do not have higher intakes of added sugar and have less intake of sodium and saturated fat than those who do not eat cereal. Taking a broader view, Ludmer characterized the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) as the first food-as-medicine program. It emphasizes positive food and nutrients first with health outcomes in mind, she said, while including foods that complement one another and provide diversity in the diet. Although she acknowledged that not all the foods in the WIC program may meet the proposed FDA definition of healthy, she asserted that they offer important nutritional advantages and have shown remarkable health outcomes for participants.

In closing, Ludmer highlighted Kellogg’s focus on driving increased redemption within the WIC program, as currently only 60 percent of people redeem their WIC cereal dollars. She stressed that Kellogg is committed to continuing to advocate for positive nudges toward healthy foods.

SEASON HEALTH

Josh Hix, Season Health, characterized his company as a food-as-medicine platform, offering three primary interventions to help drive health outcomes: clinical services, a food marketplace, and benefit assistance. Changing the food environment digitally around a consumer can be impactful, he maintained, and he shared health outcomes based on Medicaid data showing positive changes in markers such as hemoglobin A1C (blood glucose) levels, body mass index, and blood pressure in just 90 days by putting a consumer-grade intervention in front of the patients or the health plan member. He observed that, taken together, the above three interventions map to comments by previous speakers on choice architecture, changing the food environment, and making the healthy choice the obvious choice.

Elaborating on the three Season Health interventions, Hix explained that the company’s virtual clinic offers engagement with registered dietitians for support; the marketplace offers diverse food options and medically tailored meals; and the benefits bank works with food credits, waivers, and program benefits such as the Supplemental Nutrition Assistance Program (SNAP) and WIC so that participants can make the most of their available funding to change their dietary behaviors. He noted that while Season Health is a for-profit business, the only way it gets paid is by driving health outcomes, and it does not monetize any of the food options provided. He added that the company’s focus is on populations already living with chronic disease, but he is hopeful that in several years, this model will also be scaled and reimbursed for preventive care in healthier populations.

DISCUSSION

Speakers and participants discussed the importance of the cultural appropriateness of foods, choice architecture, and how labels can influence consumer decision making. Addressing consumer testing and cultural appropriateness of foods, Hix replied that Season Health pairs members with a dietitian for culinary and nutrition education. He explained that the company emphasizes the right alignment and incentives with health plans to offer the widest possible variety, and in some locations that have the necessary density of health plans, it establishes local kitchens and suppliers, contingent on a threshold density of health plan members who have the funds, typically sponsored through a combination of public benefits such as SNAP and WIC and health plan benefits, to support this model. In this way, he added, people from the community are most likely preparing the food, which may be a healthier version of a local or cultural favorite. The company also partners with local kitchens and community-based organizations to give members an appropriate amount of choice.

Another participant asked for suggestions on how to make the healthy choice the easy choice. Palma replied that consumers tend to perceive a trade-off between health and taste in food, so food labels need to balance the two. He noted that there is limited “real estate” on a food label, so advertising experts must decide how much of that space should be used to promote the healthfulness of products and how much to say that the food is tasty. Ludmer echoed Palma, saying that when people are told that a product is good for them, it often does not sell. She suggested working with retailers to promote items that can easily be used to build a healthy meal so the consumer does not have to think about what to make and which items are needed for each meal.

Abiero identified several touch points that can be used to influence the consumer in partnership with input from health experts, such as the use of tags on groceries highlighting low sodium or low sugar content. Hix noted that Season Health designs nudges based on patients’ needs. For example, patients with kidney disease see white bread by design, whereas patients with diabetes see whole-grain bread as their option. At the same time, he explained, the platform tries to ensure that it is offering numerous options that account for the preferences of both patients and their families or members of their household.

Finally, a question was raised about the changes taking place with food labels, whether products can be called healthy or certain nutrients can be highlighted. Ludmer said that Kellogg is advocating for front-of-package systems but that this approach has seen limited success in other countries. She noted further that the positive attributes of a food are difficult to get across on a label. Palma added that people navigate through the grocery

store very quickly, and eye-tracking research has shown they do not spend much time looking at labels; instead, they often go to aisles where they know familiar items are located. Finally, Abiero called attention to a point made by previous speakers that the discussion can at times still focus on rating individual products instead of assessing overall diet quality or patterns. To advance progress, she argued, more attention is needed on the dynamic elements of the dietary patterns of individuals.