Research

Prize-Winning Behavioral Economics

Earlier this month, Professor Richard Thaler at the University of Chicago Booth School of Business won the 2017 Nobel Prize in Economics. Professor Thaler’s work in behavioral economics has impacted our understanding of human behavior, and has also influenced government's’ approach to behavior as well.

 

A recent article in the New York Times explains some of Thaler’s work and contributions. Standard economic theory assumes that human beings behave “rationally.” Economists knew this was not precisely true, but operated on this assumption for a long time. Professor Thaler pushed the field to try to truly model human behavior by observing the fact that humans consistently behave in ways that deviate from what is expected - in other words, even if people behave “irrationally,” we can still model and predict their behavior.

 

Professor Thaler has found, for example, that people who own a good will value it much more than other people who do not own that good. This is called the endowment effect. This could suggest, for example, that people who own fitness technology or pedometers might value them more than other people do. If they value them more, Thaler’s work suggests that people may be more likely to use them.

 

Thaler also found that people will punish what they perceive to be unfair behavior, “even if they do not benefit from doing so.” It would be interesting to see the link between this sort of behavioral finding and application to health care and children’s health. Since there are so many actors involved in children’s health - the children themselves, providers, teachers, public officials, parents and guardians, and more - unfair practices or policies could be a real complaint that affects relationships between these actors.

 

Thaler hopes that behavioral economics, now part of mainstream economics, will move beyond the discipline alone to become an integral part of how we think about human behavior. More research in its intersection with health and children’s healthcare will be very exciting to see!

 

Children's Health Insurance: Legislation and Impact Today

On September 30th, the Children’s Health Insurance Program (CHIP) will be up for renewal in Congress, according to NPR. This “popular federal state-program” provides health insurance for more than 9 million children of families who may otherwise be unable to afford health care.

 

Some health experts fear that CHIP’s deadline will fall by the wayside while Congress deals with urgent matters in providing relief for Hurricanes Harvey and Irma. In addition, they also fear that fierce division within Congress and budget-related government shutdowns could push CHIP down the priority list. As a result, states would be left with no choice but to start scaling down the reach of CHIP, leaving many children without health insurance at a point in their lives when regular healthcare is crucial.

 

Among the multiple reasons for the importance of CHIP, one that stands out is the population of children it affects the most. The children who currently benefit from this program come from families who are in lower- or middle-income brackets but do not qualify for Medicaid. As a result, they may be forced to pay more medical bills out of pocket, increasing health and economic insecurities among this population.

 

Since its adoption in 1997, CHIP has enjoyed bipartisan support, and has been a big factor in the reduction of uninsured children from 13.9 percent in 1997 to 4.5 percent in 2015. Its impact is universally acknowledged, but up for immediate debate are the enhancements the 2010 Affordable Care Act added to CHIP. The ACA increased federal spending for CHIP by 23 percentage points, but “forbid states to restrict eligibility rules.” However, like the ACA as a whole, these enhancements may be changed in the near future.

 

The need to renew and secure CHIP’s future is urgent. Without congressional action, several states could run out of CHIP funding as soon as next year. While CHIP could be reauthorized “with no strings attached,” its uncertainty means that parents, health care providers, and community members should stay aware of its status. This is crucial if we believe, as we do here at CHIL, that the health of children is a bipartisan, long-term priority.

Friends for Life - They're Lifesaving

A quick Google search on friendships and its correlation to health results in many articles concerning the elderly, but a new study has focused on studying teens, for whom the conversation around mental health is especially important. Child Development recently found that close friends among adolescents can have lasting mental health benefits, which can be carried into adulthood, according to NPR.

 

The study, conducted over 10 years, followed 169 15-year-olds until they were 25-years-old. At age 15 and 16, researchers asked participants to record conversations with their friends. Teenage friends discussed the importance and level of trust and communication that was in their relationship at the time. Then, the participants completed annual surveys about their levels of anxiety and self-worth.

 

Researchers found that after 10 years, teenagers with strong, close friendships were more likely to report an improvement in anxiety and self-worth at age 25 than adults who did not have strong emotional links to their friends as teenagers. Stable friendships - especially same pairs of friends who showed up together year after year - seemed to provide participants with the greatest mental health gains.

 

The implications are fairly strong here. Teenagers who find support among each other are more likely to be able to weather challenges that they may face, according to the authors of the study. They also learn how to maintain close, important relationships from a young age, which lays the foundation for future healthy relationships.

 

At CHIL, our projects encourage friends to engage with each other as they participate in activities that can benefit their health. Friendships and teamwork go hand in hand, and a close friendship can be an extra incentive for children and students to invest time in themselves and each other. The importance of friends is a theme that pops up over and over again, but it should not become a cliche - it can really have an impact on a young person’s health in the long-term.

New School Lessons: Eating Healthy

We hear a lot about the obesity epidemic in the United States, especially among children and adolescents. However, the impact that school meals have on childhood weight and overall health has been overlooked. A piece in the Wall Street Journal earlier this year looks at five creative ways schools can encourage students to eat more healthily. These interventions have been formulated to help schools meet the guidelines under the Healthy Hunger-Free Kids Act of 2010.

 

Intervention One: Product Placement

Salad bars that feature at the front, or in the center, of a school lunch line are much more likely to attract students. Some Maryland elementary schools opened all-you-can-eat salad bars that featured five different fruits and five different vegetables a day and saw the number of students buying salad go up. In fact, one study found that strategic placement of vegetable options can increase consumption by as many as five times. Other schools planned the timing of vegetable snacks, so that hungry students were more likely to reach for them before a meal.

 

Intervention Two: New and Improved Advertising

Changing children’s preferences can be as simple as slicing up fruits for those with orthodontic appliances, or using more colorful bins to display fruits at lunch. “Stealth nutrition,” according to the WSJ piece, can also come in the form of food names that appeal to a young crowd (e.g. “X-Ray Carrots or Turbo Tomatoes.”) Attention-grabbing cartoon stickers on fruits can also increase consumption.

 

Intervention Three: Tracking Real Consumption

This is an intervention that can reduce waste, and at the same time, determines which foods are popular with students and which are not.  Researchers at some Chicago elementary schools recorded what foods were purchased and thrown out in order to determine the relative popularity of certain food groups.

 

Such measures can also increase parental involvement: some schools send home weekly report cards that record what a child ate throughout the week, based on lunch swipe summaries. Instead of remaining in the dark about what their children eat at school, parents can talk with their children about their meals or even compensate for missing nutrients at home.

 

Intervention Four: Bring in the Experts

Children can’t be expected to enjoy food that adults would also avoid. Chefs can consult for school menus or cook directly in schools. Over time, partnerships with chefs and local food sources can have a big impact.

 

Intervention Five: Field Trip!

Nutrition education should not have to be boring. In fact, it absolutely should not be, since a child’s first impression of a food item is crucial. Some elementary schools have started taking students on field trips to local farms, teaching ways of sustainability along with familiarizing students with new fruits and vegetables. They encourage students to make note of how a fruit smells, or what color a vegetable might be.  In NYC, the Wellness in School Program encourages students to make healthy choices for themselves based on what they observe in the fresh produce and nutrition labels they encounter.


 

Childhood Staple, Harmful Chemical?

A recent study, described in the New York Times, found that many types of boxed mac and cheese contain phthalates, a potentially harmful chemical that has already been banned in children’s toys. According to the article, phthalates are “industrial chemicals used to soften plastics and are used as solvents, in adhesives and in ink on packaging.”

 

Although the chemical interferes with hormones and has been linked to birth defects, the FDA has yet to ban phthalates. The chemical can be found in many processed foods, including mac and cheese. Two million boxes of mac and cheese are sold a day in the United States. Among the types of mac and cheese tested for phthalates, “organic” varieties also tested positive for the chemical with some products containing as many as six different phthalates.

 

Since processed foods are often more affordable and accessible than fresh, unprocessed foods, children with less access to healthy foods might be more risk for health problems. Even processed foods labeled as “organic” are likely to be more expensive yet do not offer the clear superiorities to other foods that might be implied.

 

The findings in the article show that it can be difficult to avoid dangerous chemicals, especially found in many unprocessed food. It will take real effort on the part of the consumer as well as regulatory bodies in order to protect children’s health.

The Public Health Crisis We Aren't Talking About

The Editorial Board of the New York Times wrote a piece last week calling attention to a public health crisis that does not get enough attention: the lethal combination of gun violence and children. According to a report in Pediatrics, cited by the Board, about 7,100 children are killed or sent to the hospital each year with gun-related injuries. That translates to about 25 children who are killed by guns each week. This rate is far beyond that of any other wealthy nation in the world.

 

The disparities among the pediatric victims are, discouragingly, along geographic and class lines.  African American children are at far greater risk for gun-related injuries, as are boys and children living in the South. At the same time, however, deliberate gun deaths among children are distinctly related to white or American Indian children, according to the study.

 

Even the most cursory research indicates that this is an American crisis, and one that does not show any signs of improving soon. However, the most striking aspect of this crisis is the inability of federal agencies to conduct meaningful research on guns in the country. The passing of a congressional amendment several years ago “forbid[s] federal money to be used ‘to advocate or promote gun control.’” In other words, the government of the most firearm-dangerous country for children in the world prohibits itself from researching the effects of its laws and policies.

 

Gun violence is a distinctly American crisis that affects children from all races and socioeconomic classes. In that regard, gun violence is an unparalleled public health crisis - gun violence impacts all facets of American society, and especially its most vulnerable citizens.

Healthcare Costs and Exercising Children

An article in the New York Times describes a new study that used complex models to imagine what the health landscape of American children would look like if children exercised every day. The study found that the United States could save more than $120 billion a year in healthcare costs alone if all children exercised every day.

Researchers at the Global Obesity Prevention Center at Johns Hopkins University used computerized models that created avatars for each of the 31.7 million children in the United States currently between eight to 11-years-old. In keeping with real-life statistics, they programmed two thirds of these children to rarely exercise. The researchers then modeled each child’s calorie intake and “virtual body change” day by day, year by year, and tracked these simulated childhoods into adulthood. After these avatars reached adulthood, their health was modeled based on the predictive risk for heart disease, stroke, high blood pressure, etc.

The results were sobering. The models predicted that if eight to 11-year-olds were as inactive as predicted almost $3 trillion in medical expenses would be spent on this population. Furthermore, they would have lost productivity each year once they reach adulthood.

Even if this estimate is not perfectly precise, it is undeniable that the social price tag of physical inactivity is significant - inactive kids will grow to be sedentary adults whose health problems are not only expensive to treat but also cost the economy in lost wages and productivity. Childhood obesity and Type 2 diabetes are only some of the many risks associated with a lack of exercise.

The same researchers also looked at the counterfactual and model of  how society would benefit if these children did exercise regularly. If half of the children in the U.S. were able to receive at least half an hour of exercise three times a week (the recommendation by the Centers for Disease Control and Prevention), childhood obesity would fall and the societal costs of obesity-related disease would drop by $32 billion. 

The numbers are undeniably compelling. The societal burden of disease stemming from lack of exercise would impact us all, regardless of how healthy we imagine ourselves to be. Today’s adolescents live with an unprecedented amount of distractions that might make physical activity seem less appealing, but getting proper exercise is not only a short-term benefit but also a long-term investment.

The Social Element to Running

A recent study done by researchers at the MIT Sloane School of Management has found that runners do influence each other in their training and workout routines, according to the New York Times. Researchers collected data on 1.1 million runners around the world who had collectively run almost 225 million miles over five years. Intuitively, we predicted that friends tend to have similar running routines day to day, over time, even in different geographic locations. But we have to consider correlation versus causation: do friends influence each other's’ running habits or do people choose running friends with similar habits?

 

The study found that runners do influence each other by pushing each other to run more. For instance, if a person ran 10 more minutes than usual on a given day, his or her friends would also increase the amount of time they ran by several minutes, even in the case of inclement weather (the MIT researchers also collected weather data for the five years that the runners were monitored.) In a running network, male runners seemed to be influenced by both their male and female friends, but female runners seemed to be almost exclusively influenced by their female friends. These trends could point to habits that form during young adulthood or even sooner when we respond to social cues within our friend groups, especially with respect to athleticism or body image.

 

Running is an ideal activity to collect data on because of its integration with devices that track activity and distance. Running can also easily be a social activity: we often run with buddies or engage in friendly competition with friends to increase stamina. More importantly, running is a sport that is often more accessible than other sports. As we continue to examine the influence friends play in forming healthy habits, we should also ask ourselves how we can use studies like this to help build healthy habits for our students.

Securing a Good Start to Education

Today’s topic addresses one that may seem obvious to us, but also surprising in the United States. Children who grow up hungry in the first few years of childhood have been shown to lag behind classmates in school years later. Food insecurity, or being without reliable access to nutritious food, is a phenomenon that can be found in the United States: more than 13 million children are currently living in food-insecure homes nationwide. A recent article summarized in NPR (originally published in the journal Child Development) found that children who live in these homes before the age of five are more likely to lag behind their classmates in school socially and cognitively.

 

Also, it appears that these children don’t catch up to their peers. Researchers used data from the U.S. Department of Education from 2000 to 2006 to follow more than 10,000 children born in these households throughout their young childhood. They also interviewed the parents of these children to ask them about recent times they may have worried about food for the household. The researchers found that the younger that children were when they were exposed to food hardship, the stronger the negative effect on their performance in kindergarten (performance was measured by their ability to pay attention in class, their tendency to be hyperactive or throw tantrums, and their math and reading skills).

 

This negative effect might not be entirely attributable to the children themselves. After all, if children are hungry, then their parents are likely to be as well. The researchers affirmed that parents who are hungry can be more irritable and tired, and are less likely to engage with their children. These findings are certainly not surprising, but they confirm some important facts about early childhood and the important link between nutrition, parent interaction, and school performance. It is difficult to design interventions for very young children before they attend daycare or preschool, but the projections from this stage in life to performance in school cannot be ignored.


Food insecurity is definitely not just a foreign phenomenon, and not just an adult one. That there are millions of American children at risk of being insufficiently prepared for school should shock us all - but thanks to this kind of research, we’ll be able to lay the groundwork for erasing this gap in potential for children starting now.

Setting Good Activity Goals

Today we’re continuing our segment on technology and our efforts to be less sedentary. In trying to be more physically active, it’s often most effective to set goals and work towards them each day. Goals can be individual ones or benchmarks for groups of friends or family members. But how do we set goals that work best for us?

 

A popular goal for daily physical activity is 10,000 steps per day. It’s become a catchphrase for the makers of exercise gadgets and wearable technology, but the number “10K a day” is not one that has a lot of scientific research behind it. In fact, a recent New York Times article says that a better goal might be 15,000 steps per day. Studies that arrive at approximate numbers like these often look at certain populations at a time - the study described in this article looked at postal-service walkers, many of whom were older and walked a lot each day. Also, the benefits of this sort of exercise look at health conditions that often do not manifest themselves until later in life (e.g. risk of heart disease).

 

Universal goals like these numbers only offer a simplistic approach to quantifying adequate exercise. (15,000 steps a day is apparently the equivalent of walking briskly for two hours at a 4mph pace.) What does this number mean for children who often need to be very active, but also must spend hours sitting at school each day in class? And even among children, different individuals have different needs or circumstances that might make walking 15, 000 a day a tricky goal.

 

Future research could have real potential for impact if it looks at what ideal exercise for children looks like. Federal guidelines already recommend brisk activity nearly every day for young children, but since many children and teenagers are eager to take advantage of new technology to monitor their activity, researchers should investigate what activity levels are ideal and safe for these users.  


 

Sunlight and Your Eyes: A New Link?

Here’s a quirky idea: computer and television screens can damage eyes because the lack of sunlight can reshape the eyes and impair vision over time, according to a growing community of researchers. A new article in the New York Times cites a study published recently in the Journal of the American Medical Association (JAMA Ophthalmology) that offers an explanation for the growing prevalence of myopia, or nearsightedness, especially in children and young adults.

 

Nearsightedness is a condition in which the eyeball is longer than normal, altering the angle at which light meets the eye, which can cause problems for people when focusing on faraway objects. It is a condition that really illustrates the debate between “nature and nurture” -- even if you develop it as a child, nearsightedness can progress as you become an adult depending on a complex calculus of genetics factors and the environment.

 

Volunteers were given eye exams and asked how much time they spent outside during their childhood. Researchers found a strong correlation between “current eyesight and lifelong exposure to sunlight.” It’s important to remember that this particular study was a survey and not an experiment where the researchers imposed certain conditions to, say, measure the effect of sunlight exposure on prescriptions for eyeglasses. The researchers observed a trend where those who had been exposed to the most sun as teenagers were less likely to be nearsighted in middle age.

 

The link is not necessarily a causal one, but the implications are clear. Despite the fact that excessive exposure to sunlight certainly poses its own dangers, such as the risk of skin cancer, a healthy amount of exposure can really be positively correlated to multiple aspects of health, including vision. The observed correlation between sun exposure and healthy vision only strengthens the case against excessive exposure to screens and monitors indoors. Moderation is key, but it looks as if we are still unlocking the many benefits the sun has to offer.

Medical Advice with a Grain of Salt

Today’s blog post talks about a tricky subject. A pediatrician recently wrote an article in The Upshot for the New York Times called “The Whiplash from Ever-Changing Medical Advice.” We’re constantly swamped with new findings about food, lifestyle, gadgets, or habits that could help us or harm us, according to the medical community. The author of the article, Dr. Aaron Carroll, notes that while medical researchers need to publish their work and news organizations need to report these findings, sometimes these results have a neutral effect at best. Other times, new results could actually reverse previous research that was released only a few years ago, which may confuse the general public.

 

The eternal debate about food allergies is a good example. Recently, the National Institute of Allergy and Infectious Disease recommended that we begin giving babies peanut extract or powder in their food before they are six months old, in order to reduce the odds that they develop peanut allergies. There was substantial evidence for the effectiveness of this method, especially for children who were at risk of developing these allergies.

 

Yet back in the early 2000s, the American Academy of Pediatrics warned against giving children who were at risk of developing peanut allergies any peanut-derivative products before the age of three. In hindsight, this recommendation might have actually increased the number of children with these allergies.

 

This “medical whiplash” about conflicting advice can really exhaust readers, especially parents who are trying to make healthy decisions on behalf of their children. Dr. Carroll has written articles expressing his concerns that these recommendations, “which were not supported by strong evidence, may be doing more harm than good.”


Physicians like Dr. Carroll will be the first to agree that “simple lifestyle changes may be more influential than many medical interventions.” Interventions that work for some people might not work for others, but not all medical or news organizations will definitively admit that. It’s important to keep moderation in mind as a priority, and to be receptive but critical of the plethora of medical research that comes out every day.   

Social Incentives for a Healthy Lifestyle

 

A recent article in the New England Journal of Medicine argues that the infrastructure to harness healthy habits already exists within our social interactions. The support from friends and families can help us make healthy decisions on a daily basis. The article outlines five rungs of social incentives used to improve patients’ health and to test their effectiveness. Here is a short description of each of the rungs illustrated in the article:

 

Rung One: “Patients have no explicit social engagement.”

Since health is at once a public and a private matter, some of our most important daily health maintenance routines are invisible to the world. The authors point out that our health can be invisible even to us - without a pedometer, we don’t have a grasp of our daily activity. Realizing the correlation between self-awareness and developing healthy habits, CHIL has partnered with New York City schools to bring pedometers to students. Read more about our pedometer program.

 

Rung Two: Patients’ activities, outcomes, or goals are visible to others.”

In order to encourage healthy behavior, you and your family can physically partake in habits, such as taking daily medications and vitamins, in a visible place. Restaurants have started to use this model to promote handwashing by moving the sink out of the bathroom and into a more public space.

 

Rung Three: External support is explicitly established.”

Signing up for external support, such as text alerts, to remind you and your kids to exercise can increase healthy outcomes. For everyday challenges, such as lowering blood sugar levels, simple interventions like weekly phone calls with a mentor can be more effective than expensive drugs.

 

Rung Four: “Interventions leverage reciprocity.”

It’s all about being committed to a friend’s goals as well as your own regardless of your age. Even physicians are known to work in teams to competitively improve outcomes. This element of competition can certainly energize patients combatting chronic diseases such as diabetes.

 

Rung Five:Reputational or economic incentives are layered on top of social commitments.”

This is the ultimate goal in the five-rung model. Individuals and teams can work together to create leaderboards and competitions. By doing so, there can be an increased sense of accountability as people work together toward a reward. Patients have greater potential to succeed if teammates know each other beforehand and are introduced to incentives together.